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Emergency Department Telephone Triage

Are Current Policies Safe?

Recent research found a link between Oregon patients on Medicaid and increased ED visits, with possible implications for theAffordable Care Act (ACA).   For several decades, the issue of ED overutilization has been identified as a problem.  Historically, ED visits may be preceded by a telephone triage call to the ED for assessment and disposition — which most EDs do not currently provide.  Now a “perfect storm” of ED overutilization threatens, due to the following factors: 1. ACA pent-up demand for access, 2. lack of ED telephone triage and 3. lack of alternative sites for evaluation, after hours. Ms. Wheeler explores unexamined issues linked to ED overutilization and suggests solutions to this complicated problem.

Research findings (North) indicate that patient calls to clinical call centers about some symptoms were comparable in urgency to ED visits. Based on that research, it reasonable to suspect that patient calls directly to ED may be more urgent yet, requiring formal, timely, effective assessment.  Telephone triage is designed specifically for this purpose.  Clinician use pattern recognition, context, critical thinking, problem solving processes and professional judgment to estimate urgency, and to identify urgent symptom patterns. Clinicians have performed this task adequately and successfully since 1978 (Perrin); clinical call centers have provided this service since the 1990’s.

Under ACA, ED clinical calls (and subsequent visits) will likely increase.  EDs can 1. develop formal in-house ED telephone triage system, or 2. outsource calls to a clinical call center. A third option would be a merger of Poison Center and Clinical Call Centers.   If jointly based and housed, such national, multi-functional call centers could effectively provide outsourced services 24/7, addressing a wide range of predictable but legitimate clinical calls.  Clinical Call centers could also provide after hours coverage for physicians — another area of telephone triage where patient utilization will undoubtedly increase.

The American College of Emergency Physicians (ACEP) has traditionally advocated that EDs make referrals to Poison Control Centers — a step in the right direction.  ACEP acknowledges Poison Centers, valued for their function in the current health care system. ACEP advocates funding supplied by the major stakeholders who benefit from poison center services — federal and state governmental payers and private insurance payers.  By the same token, clinical call centers perform equally valuable services (albeit more broad-based) that benefit the same stakeholders. Clinical call centers are equally deserving of ACEP recognition and ED affiliation.

Clinical Call centers have much in common with Poison Centers: both operate 24/7, are staffed with clinicians with experience and training in telephone triage, and provide safe, timely advice and disposition to patients. Both employ a systems-based approach for a range of clinical calls, from life threatening to non-acute. Both groups of clinicians perform detailed assessments, elicit context, and estimate symptom urgency.

During the after hours period (5P to 9A Mon -Fri, 24 hours a day on weekends and holidays) — a period twice as long as office hours — patient access is limited.  ED overutilization might be partially alleviated by expanded after hours access to alternative sites. Acute illness and minor injuries occur at all hours of the day, requiring, at minimum, timely access to alternative sites for evaluation.  One solution, UCLA’s Nethercutt Emergency Department, features a fast-track service for minor injuries and illnesses available daily from 11 am to 11 pm.

Current research on ED overutilization overlooks several factors.  Historically, patients have called emergency departments regarding a range of worrisome symptoms – they deserve a systematic, comprehensive response. Adequate access is negatively impacted by the combined elements of increased utilization due to ACA, the lack of ED provision of telephone triage, and the lack of access to alternative sites for evaluation after hours. 24/7 clinical call centers combined with extended hours for urgent care sites can provide safe, timely, access to care and assessment.  These policy changes are urgently needed and will alleviate some access demands now posed by ACA.

References

North F, Varkey P. How serious are the symptoms of callers to a telephone triage call centre? J Telemed Telecare 2010;16:383-8

Read articles and research from the 1980’s for more perspective on current ED telephone triage policies.

Written by Sheila Wheeler (14 Posts)

SHEILA WHEELER, RN, MS, is acknowledged as an international expert in the field of telephone triage. She has practiced nursing for over 30 years, primarily in critical care, emergency department and clinic settings. An accomplished writer, educator, researcher and consultant, Ms. Wheeler is currently President of TeleTriage Systems in San Anselmo, California.



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