Pediatric call centers fast-track urgent care

improvement OPTIMIZE YOUR BUSINESS SAVVY Pediatric call centers fast-track urgent care BARTON D SCHMITT, MD ANDREW J SCHUMAN, MD, FAAP Many pediatricians sleep well at night because they utilize call centers to respond to after-hours calls. The first call center was introduced in 1988 as a uniquely pediatric innovation. This article presents a brief history of call centers, discusses their advantages, and describes how they will improve patient care. In the mid-1970s, researchers affiliated with the Children's Hospital Medical Center (now Boston Children's Hospital) in Boston, Massachusetts, performed a feasibility study in which nonmedical "health assistants" used algorithms to refer patients for urgent care. 1 ' 2 Health assistant triage recommendations were compared with those made by emergency department (ED) physicians and nurses. In the study, 60% of callers were advised by health assistants to seek urgent care, compared with 44% of those who spoke directly with medical providers. Although the overreferral rate was striking, the study established that algorithms could be used effectively, even by nonmedical personnel. The researchers speculated that "call centers" could be developed similar to "poison centers" that were common at the time. 2,3 The firstpediatric call center was introduced in 1988 at the Children's Hospital Colorado, Aurora, with 10 subscribing physicians, and in 4 years it grew to serve 92 pediatricians. Physicians were charged on a per call basis, initially $10 per call, later decreasing to $8.25 per call. For most physicians, payments to the call center were estimated to be about 1% of practice revenue. Nurses were trained to use telephone triage protocols 4 developed by Barton Schmitt, MD, one of the authors of this article, to triage calls into 1 of 3 categories: 1) patient to be seen immediately; 2) patient to be seen next day; or 3) home advice only given. Logs were reviewed regularly, and nurses continued to receive training ; to improve their triage abilities. In the first 4 years of the program, the call center managed 107,938 calls. Fever, rash, vomiting, injury, earache, cough, diarrhea, sore throat, IN 2010, 67 MILLION OF 120 MILLION ANNUAL ED VISITS WERE AVOIDABLE. 7 fussiness, and abdominal pain were the top 10 triaged complaints (in order of decreasing frequency). Twenty percent of these calls fell into the "immediate care" category; 28% were advised to be seen the next day; and 52% were given home care advice only. One percent of calls resulted in the patient being hospitalized. 5 The call center continued to grow and serve an increasing number of Colorado pediatricians. During a THAT'S 56 A P R i L 2 017 CONTEMPORARYPEDIATRICS.COM 39

practice improvement 1-year survey conducted from 1999 to 2000,141,922 calls were answered, representing over 1000 calls per en rolled pediatrician. Disposition rates changed little from those reported 11 years earlier, with 21 % of callers advised to be seen immediately, 45% given home care instructions, and TOP H rejisows TRIAGE CALLS mm BY CALL VOLUME AT PEDIATRIC CALL CENTER, CHILDREN'S HOSPITAL COLORADO 30% advised to follow up with their pediatricians the following day.6 Eventually, many healthcare sys tems and hospitals developed call centers that served adults as well as children, and today these call cen ters receive an equal number of calls regarding adults as well as children. Overwhelmingly, physicians, pa tients, hospitals, and insurance com panies have been advocates because call centers ensure that medical care is provided in the most appropriate, most cost-effective location. Traditionally, patients are overusers of ED services. The New England Healthcare Institute (NEHI), Cam bridge, Massachusetts, estimated in 2010 that on average an ED visit costs $580 morethan an office visit, and that 67 million, or about 56%, of 120 million annual ED visits were avoidable.7 The institute estimated that more than $38 billion is wasted each year from ED overuse. It posited that reduction in costs associated with these raiiniecessary E0 visits, could!be achieved by: O Aligning patients with a medical home; O Providing primary care weekend and evening hours; and O Providing access to a call center. It is worth noting that 25% of pa tient calls to Children's Hospital Col orado's pediatric call center are from patients without a medical home. Also of note is that a recent study indicated that access to retail-based clinics did not result in a significant their initial intentions, the cost to the healthcare system would have been more than $1 million. Had the recom mendations that were made by the nurse advice line been heeded in every case, the cost to the healthcare system would have been $410,615 less than the intended services. This amount 1993 2017 translated into a saving of $42.61 per call after expenses. The conclusion: 1 Fever3 Vomiting Advice offered by call centers can save patients unnecessary healthcare costs 1 Rash Cough 3 Vomiting Urinary tract infection 4 Injury Diarrhea 5 Ear complaints Sore throat e Cough Ear pain i Diarrhea Asthma" 8 Sore throat Fever3 9 Fussiness Croup more than 32,000 calls received from 1999 to 2003. At that time, recommen dations were divided into 4 catego ries: urgent (visit within 4 hours); next day (>4 hours and within 24 hours); later visit (>24 hours); or home care Id Abdominal pain Head trauma (no visit). They discovered that com pliance with urgent and home care Fever dropped from #1 to #8. Reason: Education and reassurance reduces "fever phobia." "Asthma calls became #7. Reason: Asthma prevalence has increased. Data provided by Barton D. Schmitt, MD. reduction in low-acuity ED visits.8 A follow-up study looked at the cost savings associated with recom mendations made by the call center at Children's Hospital Colorado dur ing 2004. Researchers discovered that two-thirds of the cases in which parents reported initial intent to go to an ED or urgent care facility were not deemed "urgent" by nurse triage, whereas 15% of calls from parents who intended to stay home were triaged as "urgent."9 Had the callers implemented CONTEMPORARYPEDIATRICS.COM I A P R I L 2 017 and reduce ED overuse substantially.9 Do parents take the advice of call cen ters? To determine compliance rates as well as the frequency of underreferrals made by their call center, in vestigators affiliated with the Chil dren's Hospital Colorado reviewed calls was 74%, and compliance with next day recommendations was 44%. No deaths occurred within the week following the triage call and only 1 case per 599 resulted in hospital ization.10 In another study, there was a 90% agreement between ED refer rals made by nurses and the ED phy sicians who evaluated the patients.11 Additionally, the goal of the call center at Children's Hospital Colo rado was to achieve 0% ED underreferrals, and to always err on the side of caution and have no higher than a 10% overreferral rate. The only way that has been shown to improve upon call center triage ED referral rates is to have second-level physician triage. Doing so can reduce call center refer rals to EDs from about 20% to 10%.12

practice improvement The reason is that physicians are fa miliar with patients and parents in their practices and this familiar ity can guide recommendations. Fre quently, physicians postpone seeing the patient until the next morning. TELEPHONE TRIAGE PROTOCOLS The quality of call centers depends on multiple factors. The training of triage nurses is a key element, as is the accu rate logging of calls with recommen dations, in addition to ongoing qual ity assurance making sure that calls are triaged correctly. The call center at Children's Hospital Colorado has a monthly targeted review as part of its ongoing quality assurance program. All calls are recorded and are avail able for review. A rotation through the call center is an integral part of the pediatric resident training. The pro tocols are evidence based, reflect cur rent opinion of experts in pediatric care, follow current national guide lines, and are reviewed and updated every year. Since opening in 1988, the call center logged more than 2 million calls, and there have been no adverse outcomes during this time. As of 2016, there were more than 400 call centers usingthe Smith-Thompson Clinical Content (STCC) protocols with 20million calls logged every year. Canada has a provincial call cen ter system. Many hospitals have call centers, and many children's hospi tals nationwide provide nurse triage services. There are independent call centers, and some health insurers provide call center services. Providers should be aware that call center services are not created equal. Many centers that provide tri age for pediatric patients do not em ploy pediatric nurses. Call centers usually charge less than $1 per min- Every pediatric guideline has Some guidelines have been been reviewed by 3 or more reviewed by American pediatricians and 3 or more Academy of Pediatrics pediatric triage nurses. committees or sections. Every pediatric guideline has Guidelines are updated yearly been reviewed by 1 or more based on the changes in the pediatric emergency medicine medical literature and national physicians. guidelines (eg, the American Every adult guideline has Academy of Pediatrics and been reviewed by an adult emergency medicine physician. Every pediatric subspecialty guideline (eg, asthma, diabetes Centers for Disease Control and Prevention). Quality Improvement programs from 8 other institutions mellitus, seizures, suicide) has contribute feedback to the been reviewed by 1 or more yearly update process. pediatric subspecialists in that From: Schmitt BD"; Schmitt BD'5; Thompson DA.'6 field. ute, with most calls lasting less than 10 minutes. Many integrated health systems facilitate patient scheduling so nurses can access physician office schedules, and many hospitals are ex panding their services to proactively counsel patients discharged from the hospital to reduce readmission rates. Call center usage is changing (see page 42). Tech-savvy parents and pa tients use multiple resources to selftriage. Call centers can review videos and images sent by patients and rou- APRIL 2017 I tinely send e-mail instructions to fa cilitate compliance. It has been shown that access to a parent advice book can substantially reduce calls to triageser vices. In 1 study, distribution of a par ent advice book reduced sick visits to health maintenance organization (HMO)-affiliated medical practices by 23%, nurse advice calls by 24%, and prescriptions by 26%.13 When a health care system distributed and promoted the use of a triage app to itsmembers in 2013, ED utilization dropped by 39%.14 CONTEMPORARYPEDIATRICS.COM 41

practice improvement WHAT HAS CHANGED IN THE LAST 10 YEARS (2006-2016) Home care disposition has gone down. 46^^ 40^^ Reason Parents are using more web-based and smartphone app-based selftriage and self-care. Urgent/Emergent referral rate has gone up. Community service line calls have become a larger part of call volume. 15% 37% 2006 2011 Reason Phone number prominent in after-visit summary given to patient in the ED and clinic. Home care instructions are being e-mailed to more callers after the call. Primary care pediatricians are doing less second-level triage on patients that triage \» nurses refer to the ED or UC. 30% ^ 8% of practices of practices 2006 20116 Reason Theytrustthe call center and they have no incentive to prevent a few unnecessary after-hours ED visits. Increased technology in the rail center: ability to receive pictures and videos. Ability to submit requests More call center nurses work from liome (called "working remote"). New nurses need to be certified to do this. 2006 Remote nurses were only used to cover high-volume surges or last-minute coverage needs. Nurses mainly worked in the call center. Very few scheduled shifts were done at home. Reason Same as for home care. Fewer calls about acute illnesses and injuries that parents can safely care for at home. Consequently, less total call volume, yet same volume of calls about serious symptoms. Reason More callers request this and pediatric after-care instructions are now available in call center software. for nurse callback through an interface, bypassing the answering service. More Quality Improvement projects use outcome data. Reason EHRs provide easy access to ED encounter notes. 2016 Nurses work about 80% of their hours from home. Nurses love this option. Abbreviations: ED, emergency department; EHR, electronic health record; UC, urgent care. Data provided by Pediatric Call Center, Children's Hospital Colorado. Call centers will continue to evolve. Triage will eventually employ telehealth video technology to improve triage accuracy as well as compliance. It is also possible to recruit call centers to assist with care coordination of children with chronic or complex diseases. In addition, nurses or medical assistants, working out of a call center, can assist with many of the chores that overburden physicians today (prior authorizations, requests for routine forms/letters, and more), reducing burnout rates while facilitating access to an "integrated medical home." Watch for next month's article on how to use an office triage system to improve efficiency. For references, goto O ContemporaryPediatrics.com/ pediatric-call-centers 42 CONTEMPORARYPEDIATRICS.COM I APRIL 2017

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