Associate Editor, Journal of Family Practice.
About: “After-hours telephone triage affects patient safety,”
Will all of you who enjoy taking after-hours calls please stand up?
What? Everyone is still sitting? That’s what I thought. Although taking calls after hours is not one of our favorite duties, after-hours care is a crucial component of primary health care. The recent Institute of Medicine report, Crossing the Quality Chasm.,1 cited 6 characteristics essential for a high-quality health care system for the 21st century:
- safe
- effective
- efficient
- equitable
- timely
- patient-centered.
After-hours call coverage systems should pass muster on all 6 qualities. Do they?
Telephone triage after hours not up to standard
Hildebrandt, Westfall, and Smith provide evidence that the after-hours primary care call systems in the United States are not up to standard.2 They investigated call coverage systems of 91 primary care practices in the Denver area by phoning the office numbers, following the recorded instructions, and asking how calls were managed when they spoke to a live person. More than two thirds of the offices used answering services to triage calls, and 93% of these required patients to decide whether the condition was serious enough to warrant contacting the physician on call (this is correct!).
I suppose one could call this approach “patient-centered,” but I suspect this strategy is more to lessen the burden of the on-call physician rather than to promote safe and effective patientcentered care.
The investigators then reviewed reports of all calls not forwarded to the physician on call from 1 of these 91 practices. (A list of calls not forwarded to the physician on call is routinely forwarded to the office the next day by fax.) The physician reviewers in this study judged 50% of these calls to be potentially serious; the patients should have been referred immediately to the physician on call. Clearly, our patients are not making good decisions about the potentially serious nature of their complaints.
To be fair, only 10% of all calls were not forwarded to the on-call physician. Further, the researchers did not investigate each case to determine whether the delay in contact resulted in any untoward events that might have been prevented by immediate referral to the on-call doctor. Perhaps all of the patients needing immediate attention found appropriate care on their own by going to an emergency department or urgent care center. Further research is needed to explore the extent to which medical errors related to afterhours call procedures contribute to adverse patient outcomes.
The Institute of Medicine’s report, To Err is Human,. reminds us that the best way to prevent errors is by improving care systems rather than by attributing personal blame.3 If systems are inadequate for the job, then even the best-intentioned practitioner will provide suboptimal care. Hildebrandt and associates spotted a weakness in the system, a latent error that is easily correctable.
Solutions
What is the solution? I agree with the authors: all after-hours calls for clinical questions should be referred in a timely manner to a clinician. The clinician may be a physician, a physician assistant, or a nurse practitioner. After-hours call systems should be monitored periodically to ensure the systems are safe, effective, efficient, equitable, timely, and patient-centered. Patient complaints about suboptimal after-hours care should be investigated promptly. Continuous quality improvement principles should be applied to assess and improve after-hours care systems, just as we use them to improve office care.
I see no reason to wait. Check out your own after-hours coverage system today to ensure that all clinical calls reach the attention of a competent clinician as soon as possible. You might get another call or two each night you are on call, but I believe the gain will be worth the pain.