AFTER-HOURS TELEPHONE COVERAGE - THE APPLICATION OF AN AREA-WIDE TELEPHONE TRIAGE AND ADVICE SYSTEM FOR PEDIATRIC PRACTICES

Background. After-hours telephone calls are a stressful and frustratin g aspect of pediatric practice. At the request of private practice ped iatricians in Denver, a metropolitan area-wide system was created to m anage after-hours pediatric telephone calls and after-hours patient ca re. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours t elephone triage and advice for the patients of 92 Denver pediatricians , representing 56 practices. Objectives. This report describes the AHP , presents data from 4 years' experience with the program, and describ es results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. Methods. A fter-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and ana lyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of a fter-hours patient care encounter forms assessed the necessity for aft er-hours visits triaged by the AHP. An analysis of the total cost of t his program to 10 randomly selected subscribing physicians was conduct ed using current AHP data and a survey of the 10 physicians. Results. In 4 years, 107 938 calls have been successfully managed without an ad verse clinical outcome. Minor errors in using protocols occurred in on e call out of 1450 after-hours calls. After-hours phone calls necessit ated an after-hours patient visit 20% of the time and generated one af ter-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were giv en home care advice after-hours and seen the next day in the primary p hysician's office. Of all patients directed by the telephone triage nu rses to be seen after hours, 78% were determined to have a condition n ecessitating after-hours care. Data are presented regarding call volum es by time of day, day of week, patient age, and patient's initial com plaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all aft er-hours calls. Utilization by subscribing physicians is described. Sa tisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participatin g Denver pediatricians (which includes revenues ''given up'' as a resu lt of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. Conclusions. Lar ge-scale after-hours telephone coverage systems can be effective and w ell-received by patients, parents, and primary physicians. Data presen ted in this report can assist in planning the training of personnel wh o provide after-hours telephone advice and triage. Controversies assoc iated with this type of program are discussed. Suggestions are made re garding the direction of future programs and research.