Appropriateness of urgent referrals by nurses at a hospital-based pediatric call center

Objectives: To evaluate (1) the appropriateness of the after-hours referral (AHR), (2) clinical characteristics of urgently referred patients, and (3) parental compliance with disposition recommendations by the After-Hours Ca ll Center of the Children's Hospital, Denver, Cole. Subjects: Patients of Denver, Cole, pediatricians who called after office h ours were triaged by nurses using a computerized triage system, and were re ferred for after-hours evaluation to 1 of 5 urgent care sites (N = 409). Design: Data were collected at each site for 2-week periods every 3 months, from October 1996 to October 1997 (total study period, 10 weeks). Appropri ateness of AHRs (diagnoses, clinical interventions, and final dispositions) were determined by a questionnaire that was completed by the evaluating ph ysician. Parental compliance with the AHR was assessed by review of the aft er-hours site patient database and by telephone survey. Results: Of the referred patients, 339 (82.9%) complied with the recommenda tion for AHR and, of these, physician questionnaires were completed for 332 (97.9%). The mean percentage of evaluated patients judged appropriate was 90.7% and did not differ statistically by site or by physician training. A history indicating a potentially serious condition was the most common reas on for judging a referral appropriate (80.1%), followed by patient discomfo rt (53.3%), findings from a physical examination (42.5%), parental anxiety (41.5%), and an urgent need for diagnostic test or therapy (34.7%). Of eval uated patients, 37.0% had a diagnostic test, and in 43.5% of cases, the eva luating physician thought a therapeutic intervention was necessary that nig ht. Of the total sample, 93.4% were discharged and 6.6% were admitted to th e hospital. The major reasons given by families for noncompliance were lack of understanding of the disposition recommendation and disagreement with t he need for urgent referral. Conclusions: Approximately 90% of patients who complied with a referral for urgent evaluation by the After-Hours Call Center were judged by the evalua ting physician to have been appropriately referred. The appropriateness rat e for all referrals may be lower if there is significant self-selection in those families who do not comply.