After Hours Call Centers - Quality and Safety

Barber JW, King WD, Monroe KW, Nichols MH. Evaluation of emergency department referrals by telephone triage. Pediatrics. 2000;105(4 Pt 1):819‐821. doi:10.1542/peds.105.4.819. PubMed Abstract.

Study demonstrated that ED visits made by nurse telephone triage referral were 33% more appropriate than patients making self-referrals to the ED (80% vs. 60% of visits deemed appropriate).

Belman S, Chandramouli V, Schmitt BD, Poole SR, Hegarty T, Kempe A. An assessment of pediatric after-hours telephone care: a 1-year experience. Arch Pediatr Adolesc Med. 2005;159(2):145‐149. doi:10.1001/archpedi.159.2.145 PubMed Abstract.

Descriptive study of the Denver Children’s Hospital After-Hours Call Center’s data on 142,000 calls from June 1999 to June 2000. 

Belman S, Murphy J, Steiner JF, Kempe A. Consistency of triage decisions by call center nurses. Ambul Pediatr. 2002;2(5):396‐400. doi:10.1367/1539-4409(2002)002<0396:cotdbc>2.0.co;2. PubMed Abstract.

Nurse concordance study documenting 80% agreement among nurses taking intermittent and blinded simulated calls.

Kempe A, Bunik M, Ellis J, et al. How safe is triage by an after-hours telephone call center?. Pediatrics. 2006;118(2):457‐463. doi:10.1542/peds.2005-3073. PubMed Abstract.

Regarding safety, the potential under-referral rate to an ED for patients later needing hospitalization was 1:600 calls, using data from Denver Kaiser-Permanente patients.

Kempe A, Luberti A, Belman S, et al. Outcomes associated with pediatric after-hours care by call centers: a multicenter study. Ambul Pediatr. 2003;3(4):211‐217. doi:10.1367/1539-4409(2003)003<0211:oawpac>2.0.co;2. PubMed Abstract.

Regarding safety, the potential under-referral rate to an ED for patients later needing hospitalization was 1:500, using data from 4 pediatric call centers (Denver, Cleveland, Philadelphia and St Petersburg). 

Kempe A, Dempsey C, Whitefield J, Bothner J, MacKenzie T, Poole S. Appropriateness of urgent referrals by nurses at a hospital-based pediatric call center. Arch Pediatr Adolesc Med. 2000;154(4):355‐360. doi:10.1001/archpedi.154.4.355. PubMed Abstract.

Based on the assessments of the ED physicians who evaluated the children sent there by the after-hours triage nurses, 90% were appropriate referrals needing urgent care.

Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics. 1993;92(5):670‐679. PubMed Abstract.

Original report of Denver call center performance (1988-1992) before it became computerized.

Scarfone RJ, Luberti AA, Mistry RD. Outcomes of children referred to an emergency department by an after-hours call center. Pediatr Emerg Care. 2004;20(6):367‐372. doi:10.1097/01.pec.0000133610.42699.41. PubMed Abstract.

Study reports the outcomes and clinical characteristics of children referred to the ED by an after-hours call center. Data such as these may be used by call centers in the assessment of management advice and referral practices.

Schmitt BD, Schuman AJ. Pediatric call centers fast track urgent care. Contemporary Pediatrics. 2017; 34(4): 39-42. Contemporary Pediatrics Article.

Benefits of pediatric call centers to community pediatricians.

Wheeler SQ, Greenberg ME, Mahlmeister L, Wolfe N. Safety of clinical and non-clinical decision makers in telephone triage: a narrative review. J Telemed Telecare. 2015 Sep;21(6):305-22. PubMed Abstract.

This study compared four groups of potential telehealth triagers: clinicians (physicians, nurses) and non-clinicians (emergency medical dispatchers and clerical staff). Nurses had the highest average appropriate referral (AR) rates (91%) followed by physicians' (82%). These results are possibly explainable by focused triage nurse training, nurse critical thinking, and nurse adherence to guidelines.

After Hours Call Centers - Cost Benefits

Brown K, Tabone G, Thompson DA. The impact of telephone triage on healthcare costs – an analysis of caller intent and outcomes. 2018. Abstract and Chart.

This study suggests that there could be substantial potential improvements in patient safety and cost savings for the health care system.

Bunik M, Glazner JE, Chandramouli V, Emsermann CB, Hegarty T, Kempe A. Pediatric telephone call centers: how do they affect health care use and costs?. Pediatrics. 2007;119(2):e305‐e313. doi:10.1542/peds.2006-1511. PubMed Abstract.

Study compared nurse triage to caller prior intent. Study demonstrated cost-effectiveness of nurse triage. 

Cooper IR, Schmaus A, Whitten TA, Bakal JA, Kurji F, Watt D, Lang E. Descriptive analysis and evaluation of Health Link referrals to the emergency department before and during the COVID-19 pandemic. Intern Emerg Med. 2024 Feb 22. PubMed Abstract.

Referrals from the Health Link call center to the emergency department (ED) made up only a small portion of all ED visits. According to study criteria, most referrals to the ED were appropriate. Interestingly, the COVID-19 pandemic did not significantly change the number of Health Link calls leading to ED referrals or the appropriateness of those referrals.

Kempe A, Dempsey C, Hegarty T, Frei N, Chandramouli V, Poole SR. Reducing after-hours referrals by an after-hours call center with second-level physician triage. Pediatrics. 2000;106(1 Pt 2):226‐230. PubMed Abstract.

Second-level triage and advice provided by the on-call PCP reduced the nurse ED referral rate by almost 50%.

Schmaus A, Cooper IR, Whitten T, Bakal J, Watt D, Huang J, Lang E. Impact of Health Link utilization on emergency department visits. CJEM. 2023 Apr 23. Epub ahead of print. PubMed Abstract. Full Text in Canadian Journal of Emergency Medicine.

In the United States the most commonly used emergency department triage scoring system is the Emergency Severity Index (ESI). Emergency departments in Canada use the Canadian Triage Acuity Scale (CTAS). The study by Schmaus, et.al. showed that emergency department patients previously triaged by the Alberta Health Link were sicker or more injured (CTAS 1-3) than people who presented directly to the emergency department without prior Alberta Health Link triage. This difference was even more pronounced in people that lived in rural areas. There were 900,196 telephone triage encounters during the 2018 to 2019 study period.

After Hours Call Centers - Patient Satisfaction

Kempe A, Luberti AA, Hertz AR, et al. Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance. Pediatrics. 2001;108(6):E111. doi:10.1542/peds.108.6.e111. PubMed Abstract.

93-99% of callers were satisfied with nurse triage at 4 children’s hospitals.

Office-Based Nurse Triage and Advice

Schmitt BD: Calls about sick children: A triage system for the office. Contemporary Pediatrics 1998, 15(7):138-152. PDF.

The system described in this two-part series will help you delegate your office sick-child calls.

Schmitt BD: Calls about sick children: Launching your Own Triage System. Contemporary Pediatrics 1998, 49-71. PDF.

This article describes how to hire and train a triage nurse, limit medical liability, deal with cost and capitation issues, arid help parents adapt.

Telehealth Triage Operational and Utilization Data

Marks GA, Thompson DA.  Top 25 Adult and Pediatric Office-Hours Telehealth Triage Guidelines Used During Calendar Years 2020 - 2022. March 31, 2023. Abstract and Chart

Analysis of top adult and pediatric triage guidelines based on 4,420,797 patients triaged during calendar years 2020-2022.

O’Bryan L, Barzin A, Thompson DA. Comparison of Pre-Call Patient Intent to Telehealth Triage Nurse Recommended Disposition. Poster presentation at AAACN Annual Meeting 2024. Abstract and Charts

This 2022-2023 study of 7,503 telehealth encounters demonstrated that nurse triage has the potential to substantially improve care and reduce healthcare costs by directing patients to get the right care, at the right place, at the right time.

Thompson DA, Feirer J. Trends in Emergency Department Visits and Hospital Deaths During the COVID-19 Pandemic: A Comparative Analysis of CDC and Telehealth Call Center Data. September 15, 2023. Abstract and Charts

There were parallel trends between ED visits, hospital deaths and telehealth call center encounters during the COVID-19 pandemic.

Thompson DA, Marks GA.  Top 25 Adult and Pediatric After-Hours Telehealth Triage Guidelines Used During Calendar Years 2020 - 2022. March 22, 2023. Abstract and Chart

Analysis of top adult and pediatric triage guidelines based on 3,289,976 patients triaged during calendar years 2020-2022.