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- All clinical after-hours calls should be forwarded to the on-call physician, and no triage decisions should be made by the answering service or the patient, who may erroneously and dangerously delay medical care.
- Physicians in this study who reviewed the content of after-hours calls judged not to be emergencies said they would have wanted to talk to the patients in approximately half the cases. As only 10% of after-hours calls are judged nonemergencies, talking to all the after-hours clinical calls would result in only a small increase in the number of cases handled by the on-call physician.
Objective: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment.
Study Design: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage.
Population: Primary care physicians and their telephone answering services.
Outcome Measures: (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls.
Results: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%–77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician.
Conclusions: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.
We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.1 In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.
The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,2,3,4 and the management of these calls by professional and nurse triage services have been studied.5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.
Methods
This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study1 that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.
Survey of primary care physicians’ answering services
The physicians in each specialty were identified in their respective section of the telephone book,7 and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.
Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.
If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.
Analysis of phone calls classified by patients as nonemergent
In our previous study,1 we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.
For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.
Results
Survey of primary care physicians’ answering services
Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”
After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,5 and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.
Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.
A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.1
Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.
Analysis of phone calls classified by patients as nonemergent
Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).
TABLE 1
Telephone triage summary by specialty
| Values are percentage of Yes answers. | ||||
|---|---|---|---|---|
| All specialties | Family practice offices | Internal medicine offices | Obstretric/gynecolgic offices | |
| PART 1: ALL SURVEYS | n=86 | n=34 | n=26 | n=26 |
| Is there a recorded message? | 84 | 85 | 85 | 81 |
| If an emergency, patient to call “911”? | 56 | 72 | 58 | 35 |
| After recorded message, who answers? | ||||
| Answering service | 67 | 56 | 65 | 88 |
| Nurse | 0 | 0 | 0 | 0 |
| Physician (called or paged directly) | 21 | 35 | 23 | 0 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| Ease of access | ||||
| Call 1 telephone number | 34 | 38 | 42 | 23 |
| Call a second number | 16 | 18 | 23 | 8 |
| Press telephone option number | 38 | 35 | 23 | 57 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| PART 2: ANSWERING SERVICES | n=59 | n=19 | n=17 | n=23 |
| What information is requested? | ||||
| Caller’s name | 100 | 100 | 100 | 100 |
| Patient’s name | 100 | 100 | 100 | 100 |
| Age | 52* | 83* | 41* | 35 |
| Sex | 29* | 39* | 24* | 26 |
| Pregnancy status | 76* | 95* | 70 | 96 |
| Nature of complaint | 100 | 100 | 100 | 100 |
| Who makes decision to contact physician? | ||||
| Patient | 93 | 83 | 94 | 100 |
| Answering service | 5 | 11 | 6 | 0 |
| Unknown | 2 | 6 | ||
| What happens to nonemergency calls? | ||||
| Faxed to office next day | 95 | 83 | 100 | 100 |
| Held for office to call | 5 | 17 | 0 | 0 |
| *Includes yes and sometimes responses. | ||||
TABLE 2
Sample of calls classified as nonemergent by patients
| Obstetrics |
| 41-week obstetric, leaking fluid |
| 34-week obstetric, contractions |
| 6-month obstetric, bad cold and side pains |
| Cardiopulmonary |
| Pain in chest and going down left arm |
| Chest pain, hard time breathing in |
| Had heart operation, needs to be seen |
| Trauma |
| Has multiple sclerosis, severe vertigo, fell and hit her head |
| Was in motor vehicle accident, please call |
| Cut hand last night, still bleeding in morning |
| Medications |
| Has flu, what can she take because of hepatitis? |
| Lost his inhaler, please call |
| Prescription making patient throw up every time he eats |
| Pediatric |
| 1 week old, vomiting, crying |
| 6 year old, sore throat, wheezy, fever, diarrhea, not sleeping |
| Miscellaneous |
| Needs to talk to doctor ASAP, says it’s very important |
| Please call ASAP, it’s personal |
| Vomiting due to liver scans |
Discussion
In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.
Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.
Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.
We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.8 New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”
Solutions
Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.5
Interpretations
This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.
Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.
The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”9 Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.
Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.
Acknowledgments
We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.
1. Hildebrandt D, Westfall J. After-hours calls to a family medicine practice. J Fam Pract 2002;51:567-569.
2. Jacobson B, Strate L, Gyorgy B, Huang L, Mutinga M, Banks P. The nature of after-hours telephone medical practice by GI fellows. Am J Gastroenterol 2001;96:570-574.
3. Greenhouse D, Probst J. After-hours telephone calls in a family practice residency: volume, seriousness and patient satisfaction. Fam Med 1995;27:525-530.
4. Spencer DC, Daugird AJ. The nature and content of physician telephone calls in private practice. J Fam Pract 1988;27:201-205.
5. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system of pediatric practices. Pediatrics 1993;92:670-679.
6. Reisinger P. Experiences of critical care nurses in telephone triage positions. Dimens Crit Care 1998;17:20-27.
7. Qwest Dex Yellow Pages. Englewood, CO: Qwest; 2000.
8. Luszczac M. Evaluation and management of infants and young children with fever. Am Fam Phys 2001;64:1219-1226.
9. Corrigan JM, Donaldson MS, Kohn LT, McKay T, Pike KC. To Err Is Human: Building a Safer Health System. Institute of Medicine Report 2000. Available at: http://www.iom.edu/iom/iomhome.nsf/Pages/2000 +Reports. Accessed on January 25, 2002.
- All clinical after-hours calls should be forwarded to the on-call physician, and no triage decisions should be made by the answering service or the patient, who may erroneously and dangerously delay medical care.
- Physicians in this study who reviewed the content of after-hours calls judged not to be emergencies said they would have wanted to talk to the patients in approximately half the cases. As only 10% of after-hours calls are judged nonemergencies, talking to all the after-hours clinical calls would result in only a small increase in the number of cases handled by the on-call physician.
Objective: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment.
Study Design: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage.
Population: Primary care physicians and their telephone answering services.
Outcome Measures: (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls.
Results: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%–77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician.
Conclusions: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.
We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.1 In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.
The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,2,3,4 and the management of these calls by professional and nurse triage services have been studied.5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.
Methods
This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study1 that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.
Survey of primary care physicians’ answering services
The physicians in each specialty were identified in their respective section of the telephone book,7 and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.
Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.
If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.
Analysis of phone calls classified by patients as nonemergent
In our previous study,1 we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.
For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.
Results
Survey of primary care physicians’ answering services
Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”
After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,5 and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.
Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.
A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.1
Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.
Analysis of phone calls classified by patients as nonemergent
Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).
TABLE 1
Telephone triage summary by specialty
| Values are percentage of Yes answers. | ||||
|---|---|---|---|---|
| All specialties | Family practice offices | Internal medicine offices | Obstretric/gynecolgic offices | |
| PART 1: ALL SURVEYS | n=86 | n=34 | n=26 | n=26 |
| Is there a recorded message? | 84 | 85 | 85 | 81 |
| If an emergency, patient to call “911”? | 56 | 72 | 58 | 35 |
| After recorded message, who answers? | ||||
| Answering service | 67 | 56 | 65 | 88 |
| Nurse | 0 | 0 | 0 | 0 |
| Physician (called or paged directly) | 21 | 35 | 23 | 0 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| Ease of access | ||||
| Call 1 telephone number | 34 | 38 | 42 | 23 |
| Call a second number | 16 | 18 | 23 | 8 |
| Press telephone option number | 38 | 35 | 23 | 57 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| PART 2: ANSWERING SERVICES | n=59 | n=19 | n=17 | n=23 |
| What information is requested? | ||||
| Caller’s name | 100 | 100 | 100 | 100 |
| Patient’s name | 100 | 100 | 100 | 100 |
| Age | 52* | 83* | 41* | 35 |
| Sex | 29* | 39* | 24* | 26 |
| Pregnancy status | 76* | 95* | 70 | 96 |
| Nature of complaint | 100 | 100 | 100 | 100 |
| Who makes decision to contact physician? | ||||
| Patient | 93 | 83 | 94 | 100 |
| Answering service | 5 | 11 | 6 | 0 |
| Unknown | 2 | 6 | ||
| What happens to nonemergency calls? | ||||
| Faxed to office next day | 95 | 83 | 100 | 100 |
| Held for office to call | 5 | 17 | 0 | 0 |
| *Includes yes and sometimes responses. | ||||
TABLE 2
Sample of calls classified as nonemergent by patients
| Obstetrics |
| 41-week obstetric, leaking fluid |
| 34-week obstetric, contractions |
| 6-month obstetric, bad cold and side pains |
| Cardiopulmonary |
| Pain in chest and going down left arm |
| Chest pain, hard time breathing in |
| Had heart operation, needs to be seen |
| Trauma |
| Has multiple sclerosis, severe vertigo, fell and hit her head |
| Was in motor vehicle accident, please call |
| Cut hand last night, still bleeding in morning |
| Medications |
| Has flu, what can she take because of hepatitis? |
| Lost his inhaler, please call |
| Prescription making patient throw up every time he eats |
| Pediatric |
| 1 week old, vomiting, crying |
| 6 year old, sore throat, wheezy, fever, diarrhea, not sleeping |
| Miscellaneous |
| Needs to talk to doctor ASAP, says it’s very important |
| Please call ASAP, it’s personal |
| Vomiting due to liver scans |
Discussion
In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.
Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.
Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.
We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.8 New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”
Solutions
Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.5
Interpretations
This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.
Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.
The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”9 Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.
Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.
Acknowledgments
We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.
- All clinical after-hours calls should be forwarded to the on-call physician, and no triage decisions should be made by the answering service or the patient, who may erroneously and dangerously delay medical care.
- Physicians in this study who reviewed the content of after-hours calls judged not to be emergencies said they would have wanted to talk to the patients in approximately half the cases. As only 10% of after-hours calls are judged nonemergencies, talking to all the after-hours clinical calls would result in only a small increase in the number of cases handled by the on-call physician.
Objective: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment.
Study Design: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage.
Population: Primary care physicians and their telephone answering services.
Outcome Measures: (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls.
Results: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%–77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician.
Conclusions: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.
We found recently that about 10% of after-hours calls from patients were not forwarded by the answering service to the physician on call because the patient did not think the problem was an emergency.1 In reviewing these calls, it became evident that many were indeed serious enough to require immediate contact with a medical professional.
The purpose of this study was to evaluate the management of after-hours phone calls made to primary care physicians’ offices and their answering services in a large metropolitan area. General descriptions of after-hours calls have been reported,2,3,4 and the management of these calls by professional and nurse triage services have been studied.5,6 However, the management of telephone triage by answering services has not been examined. No published data exist on the number of after-hours phone calls to US physicians.
Methods
This study had 2 components. In part 1, we surveyed 91 primary care offices (in family practice, internal medicine, obstetrics, and pediatrics) to determine how they handle after-hours phone calls. In part 2, we analyzed all calls from our previous study1 that were not identified by the patient as an emergency and, hence, not forwarded to the on-call physician.
Survey of primary care physicians’ answering services
The physicians in each specialty were identified in their respective section of the telephone book,7 and, by using a systematic sampling technique, every fifth name was selected and surveyed. All surveys were completed in October and November 2001 after regular office hours, generally between 10:00 PM and 1:00 AM.
Using a structured survey interview form, the principal investigator indicated during each call that this was an anonymous research survey and asked if the answering service personnel could answer several questions. The information collected in each 3- to 5-minute interview included: whether there was a recorded message, whether the patient was instructed to call 911, who answered the call after the recorded message, what information was requested, who made the decision to initiate contact with the on-call physician, and what happened to calls that were not forwarded.
If the patient was instructed to choose an “option” from the medical office telephone system, this option was selected if it would lead to an answering service. If it offered to call or page the physician directly, then that survey was terminated. The name of the answering service was recorded to determine how many different services were used in this metropolitan area. We did not survey offices on how they managed the phone call reports received the next day or how they managed clinical calls during regular office hours.
Analysis of phone calls classified by patients as nonemergent
In our previous study,1 we entered the chief complaint of all after-hours telephone calls made to our community-based family practice training program between April 2000 and March 2001 into an Access database program (Microsoft Access 97, Microsoft Corporation, Redmond, WA). These after-hours calls were routed to an answering service when the office was closed. Patients were asked by the answering service: “Is this an emergency?” Patients who were not certain were asked if they needed to speak directly with the physician. The calls were sent to the physician on call only if the patient stated to the answering service operator that the problem was an “emergency” or if they were uncertain and requested to speak directly with the physician.
For this study, we analyzed only the nonemergency calls that were not forwarded to a physician. We chose 4 local family physicians who were unaware of the purpose of the study to review these calls. We asked them to: “Indicate which of these complaints you want your after-hours answering service to forward to the physician on call and which can wait to be faxed to the office the following morning.” We analyzed their responses with descriptive statistics (SAS 8.0, SAS Institute, Cary, NC) and an overall multirater statistic (Magree macro 1.0, SAS Institute). The HealthOne Institutional Review Board approved this study.
Results
Survey of primary care physicians’ answering services
Table 1 presents the results of our survey of primary care physicians. Most physicians had a recorded message instructing the patient how to reach the physician after hours. In 4 cases, the message implied that the patient should not call unless that person had a “true emergency.”
After calling 5 pediatricians, it became clear that the pediatricians used a single, well-described nurse triage service for managing after-hours calls,5 and the pediatric offices were not included in further analysis. We have only partial data for 2 physicians because their answering service was too busy to complete the survey.
Fifty-six percent of the offices had recorded messages that instructed the caller to hang up and dial 911 if the problem was a “life-threatening” emergency. After the initial recorded message, 67% of the calls were answered by an answering service.
A full 93% of the answering services required the patient to decide whether to initiate contact with the on-call physician. Only those calls reported by the caller to be an “emergency” were forwarded to the on-call physician. In 2 cases, the answering service operator suggested to us that they were instructed to “use their judgment” in forwarding calls to the on-call physician. Five of the answering services commented that about 90% of the calls are forwarded to the physician and 10% are not forwarded, closely matching our previous findings.1
Ninety-five percent of the answering services faxed reports on all calls, including those not forwarded during the night, to the offices the following business day. Twelve answering services were used by the 91 practices in our study: 2 handled only family practice offices, 1 handled only internal medicine offices, 1 handled only obstetric offices, and 8 handled calls for multiple specialties.
Analysis of phone calls classified by patients as nonemergent
Over 1 year, 2835 clinical calls (eg, not administrative or appointment cancellations) were made to the office after hours, and 90% were considered to be an emergency and forwarded to the oncall physician. The remaining 10% (288 calls) were faxed to the office the next day. Table 2 shows examples of those calls that were not forwarded. Our 4 physician reviewers of the nonemergency calls wanted to speak to the patient immediately at a mean of 50% of the calls rather than wait until the following business day (range, 22%%–77%, κ=.45).
TABLE 1
Telephone triage summary by specialty
| Values are percentage of Yes answers. | ||||
|---|---|---|---|---|
| All specialties | Family practice offices | Internal medicine offices | Obstretric/gynecolgic offices | |
| PART 1: ALL SURVEYS | n=86 | n=34 | n=26 | n=26 |
| Is there a recorded message? | 84 | 85 | 85 | 81 |
| If an emergency, patient to call “911”? | 56 | 72 | 58 | 35 |
| After recorded message, who answers? | ||||
| Answering service | 67 | 56 | 65 | 88 |
| Nurse | 0 | 0 | 0 | 0 |
| Physician (called or paged directly) | 21 | 35 | 23 | 0 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| Ease of access | ||||
| Call 1 telephone number | 34 | 38 | 42 | 23 |
| Call a second number | 16 | 18 | 23 | 8 |
| Press telephone option number | 38 | 35 | 23 | 57 |
| No answer/wrong number | 12 | 9 | 12 | 12 |
| PART 2: ANSWERING SERVICES | n=59 | n=19 | n=17 | n=23 |
| What information is requested? | ||||
| Caller’s name | 100 | 100 | 100 | 100 |
| Patient’s name | 100 | 100 | 100 | 100 |
| Age | 52* | 83* | 41* | 35 |
| Sex | 29* | 39* | 24* | 26 |
| Pregnancy status | 76* | 95* | 70 | 96 |
| Nature of complaint | 100 | 100 | 100 | 100 |
| Who makes decision to contact physician? | ||||
| Patient | 93 | 83 | 94 | 100 |
| Answering service | 5 | 11 | 6 | 0 |
| Unknown | 2 | 6 | ||
| What happens to nonemergency calls? | ||||
| Faxed to office next day | 95 | 83 | 100 | 100 |
| Held for office to call | 5 | 17 | 0 | 0 |
| *Includes yes and sometimes responses. | ||||
TABLE 2
Sample of calls classified as nonemergent by patients
| Obstetrics |
| 41-week obstetric, leaking fluid |
| 34-week obstetric, contractions |
| 6-month obstetric, bad cold and side pains |
| Cardiopulmonary |
| Pain in chest and going down left arm |
| Chest pain, hard time breathing in |
| Had heart operation, needs to be seen |
| Trauma |
| Has multiple sclerosis, severe vertigo, fell and hit her head |
| Was in motor vehicle accident, please call |
| Cut hand last night, still bleeding in morning |
| Medications |
| Has flu, what can she take because of hepatitis? |
| Lost his inhaler, please call |
| Prescription making patient throw up every time he eats |
| Pediatric |
| 1 week old, vomiting, crying |
| 6 year old, sore throat, wheezy, fever, diarrhea, not sleeping |
| Miscellaneous |
| Needs to talk to doctor ASAP, says it’s very important |
| Please call ASAP, it’s personal |
| Vomiting due to liver scans |
Discussion
In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.
Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.
Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.
We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.8 New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”
Solutions
Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.5
Interpretations
This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.
Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.
The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”9 Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.
Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.
Acknowledgments
We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.
1. Hildebrandt D, Westfall J. After-hours calls to a family medicine practice. J Fam Pract 2002;51:567-569.
2. Jacobson B, Strate L, Gyorgy B, Huang L, Mutinga M, Banks P. The nature of after-hours telephone medical practice by GI fellows. Am J Gastroenterol 2001;96:570-574.
3. Greenhouse D, Probst J. After-hours telephone calls in a family practice residency: volume, seriousness and patient satisfaction. Fam Med 1995;27:525-530.
4. Spencer DC, Daugird AJ. The nature and content of physician telephone calls in private practice. J Fam Pract 1988;27:201-205.
5. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system of pediatric practices. Pediatrics 1993;92:670-679.
6. Reisinger P. Experiences of critical care nurses in telephone triage positions. Dimens Crit Care 1998;17:20-27.
7. Qwest Dex Yellow Pages. Englewood, CO: Qwest; 2000.
8. Luszczac M. Evaluation and management of infants and young children with fever. Am Fam Phys 2001;64:1219-1226.
9. Corrigan JM, Donaldson MS, Kohn LT, McKay T, Pike KC. To Err Is Human: Building a Safer Health System. Institute of Medicine Report 2000. Available at: http://www.iom.edu/iom/iomhome.nsf/Pages/2000 +Reports. Accessed on January 25, 2002.
1. Hildebrandt D, Westfall J. After-hours calls to a family medicine practice. J Fam Pract 2002;51:567-569.
2. Jacobson B, Strate L, Gyorgy B, Huang L, Mutinga M, Banks P. The nature of after-hours telephone medical practice by GI fellows. Am J Gastroenterol 2001;96:570-574.
3. Greenhouse D, Probst J. After-hours telephone calls in a family practice residency: volume, seriousness and patient satisfaction. Fam Med 1995;27:525-530.
4. Spencer DC, Daugird AJ. The nature and content of physician telephone calls in private practice. J Fam Pract 1988;27:201-205.
5. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system of pediatric practices. Pediatrics 1993;92:670-679.
6. Reisinger P. Experiences of critical care nurses in telephone triage positions. Dimens Crit Care 1998;17:20-27.
7. Qwest Dex Yellow Pages. Englewood, CO: Qwest; 2000.
8. Luszczac M. Evaluation and management of infants and young children with fever. Am Fam Phys 2001;64:1219-1226.
9. Corrigan JM, Donaldson MS, Kohn LT, McKay T, Pike KC. To Err Is Human: Building a Safer Health System. Institute of Medicine Report 2000. Available at: http://www.iom.edu/iom/iomhome.nsf/Pages/2000 +Reports. Accessed on January 25, 2002.