Telephone triage lines may be competing with EDs—and courting legal disaster

But are physicians any better at advising phone patients? One study raises questions

Emergency departments (EDs) have not done a good job of giving patients accurate medical advice over the telephone. Physicians and nurses have neither the time nor the inclination to counsel would-be patients on the intricacies of their medical conditions without having them physically present and subject to a physical examination.

That’s the conclusion of a large number of emergency specialists and the reason that telephone triage supplied by ED personnel has not become a standard of non-ambulance-based pre-hospital medical care. According to veteran physicians, EDs should stay out of the telephone advice-line business because they are not properly staffed or licensed to dispense telephone advice.

Yet, a growing number of managed care organizations (MCOs), including health insurers and third-party contractors, are convinced they can give out sound clinical information about sick patients over the telephone and can refer them to appropriate levels of medical care.

Advice lines are delaying needed medical care for patients

With proper training and formal clinical algorithms, telephone triage can be an effective method of redirecting patients to appropriate medical options, say advocates of ask-a-nurse telephone systems. But emergency physicians counter that these telephone advice lines, which are run largely by health plans, are dangerously courting clinical and legal disaster.

In fact, some emergency specialists feel the advice lines are delaying necessary treatment for thousands of individuals and that when patients do arrive at the ED for help, they are generally sicker and more expensive to treat than if they had come sooner.

In 1993, for example, a Georgia jury returned a $45.47 million verdict against Kaiser Foundation Health Plan of Georgia after jurors decided that delays related to a telephone triage incident worsened the condition of a six-month-old boy suffering from meningococcemia.

The boy was initially misdiagnosed by a clinic physician with a simple upper respiratory infection and was prescribed saline nose drops, a vaporizer, and Tylenol.

When the patient’s condition worsened, the boy’s mother called the MCO’s after-hours telephone line and reported that her son’s condition had worsened. The boy’s temperature had reached 104°F, and he was vomiting. He was also panting and moaning. But otherwise, he appeared limp and motionless.

The nurse who took the call advised the mother to place the child in a tepid bath. She contacted the child’s pediatrician who, according to court records, was not fully informed by the nurse on the phone about the boy’s serious condition.

Based on the sketchy information, the physician concluded that the boy’s condition was not an emergency and instructed the nurse to tell the mother to take the boy to a contracting hospital some 40 miles from the boy’s home and much farther away than other hospitals.

As a result of the delays, physicians later had to amputate the boy’s hands and lower legs. During the trial the health plan maintained that the amputations would have been necessary regardless of where the boy had been taken. But the jury found in favor of the plaintiffs.1

Not all ask-a-nurse’ services are alike

In these potentially serious cases, "MCO nurses don’t have the wherewithal to make decisions as to the appropriate level of therapy for a patient. This is especially true when the information is based on a patient’s self-assessment or a family member’s," says Vincent P. Verdile, MD, an emergency physician at Albany Medical Center in New York.

But in fairness, Verdile cautions that we shouldn’t dismiss all telephone advice lines as either dangerous or inappropriate. For one, the vast number of callers they help usually call about minor, non-life-threatening conditions.

Some advice lines restrict callers’ questions to mundane issues such as information regarding prescription refills or referrals to the network’s primary care physicians or specialists. Anything potentially more serious than that, which may require the clinical knowledge of a physician or nurse, is referred to an emergency physician, company executives claim.

"Thousands of health plan enrollees use these call lines daily. And the number of bad outcomes associated with these calls is in fact quite small," says Verdile. "The better systems use structured, physician-driven guidelines that are based on sound clinical algorithms tailored to different situations and patients," he adds.

Regional poison control centers, for example, have for years performed an invaluable service for hospitals and communities. 911 emergency call centers have also tailored their responses to individual situations, while they have attempted to cover the full spectrum of potential emergency calls.

Furthermore, MCO-operated advice lines vary considerably from health plan to health plan. There are also a growing number of third-party contractors getting into the ask-a-nurse business, and some of them are credible, according to sources.

But hospitals should be aware that these services are here to stay and they do affect the number and nature of emergency visits. But whether patients tend to delay medically necessary treatment is arguable, says emergency physician Brad Schwartz, MD.

Aside from exceptions that unfortunately make headlines, there is no evidence that advice lines tend to delay medical treatment. In fact, the opposite may be true, Schwartz says.

Call lines can help to identify serious medical conditions

If done properly, telephone advice lines help manage patients by directing them to appropriate levels of medical care, says Schwartz, chief medical officer with MedAmerica Oncall, an independent advice-line provider in San Diego, CA. The company contracts with MCO nationally.

These companies tend to see themselves in the business of demand management rather than telephone triage. These services have the potential, says Schwartz, a board certified emergency physician, to beneficially influence the utilization of medical care. They also claim to serve as a way to educate health plan enrollees concerning non-emergency conditions, which represent the bulk of callers’ concerns.

The betters ones do not play "fast and loose" with potential emergencies, says Mark Desrosiers, MedAmerica’s director of business development. "In fact, reliable advice lines staffed with trained professionals can help identify potential problems when someone calls, for example, thinking that they’re complaining about severe indigestion when it may actually be something more troublesome," Desrosiers says.

Vendors like MedAmerica, which uses nurses and physician specialists to dole out the advice, are a growing segment of the advice line business. The company is a division of Oakland, CA-based MedAmerica, which operates an emergency physician practice management concern.

Schwartz sees advice lines as a resource for emergency providers that, if properly run, can efficiently manage patient demand for both hospitals and payer. However, Schwartz does acknowledge that on-call demand management services are highly variable in quality and that no two entities, even among health plan in-house providers, are the same.

Part of the reason for this is that the ask-a-nurse industry lacks proper credentialing. At present, no external professional group accredits, licenses, or credentials advice-line providers. There are also no uniform clinical protocols or standards used by individual advice line firms, although companies are upgrading their operating guidelines and have done a better job within certain parameters, Verdile observes. But as a whole, the industry is largely unregulated.

Study questions whether physicians can do better

But can only physicians properly give out medical advice by phone? A 1992 study of telephone triage by primary care physicians found that there is considerable variability even among physicians when it comes to giving correct information to patients by phone.2

The study found that experienced physicians were likely to arrive at the same conclusions concerning patients without serious medical conditions than were first-year residents in the study. However, both residents and veteran providers were likely to underestimate the degree of illness in the patient (in this case a child) with severe diarrhea and dehydration.

This was so "regardless of the information they elicited in the telephone evaluation." However, specialists, which in the study mean pediatricians, were much more likely than primary care physicians to see the ill child promptly. "This may be because faculty physicians (pediatricians) have more contact with seriously ill children than those in private practice," the study concluded.

Whatever the case, telephone advice lines do have a place in managing patient flow to the ED. However, the only valid conclusion seems to be that these services are highly variable and should not at any time be mistaken by patients as a substitute for emergency triage, concludes Verdile.

References

1. Adams v. Foundation Health Plan of Georgia, 93-vs-7985E, Fulton County Superior Court (1993).

2. Yanovski SZ, Yanovski JA, Malley JD, et al. Telephone triage by primary care physicians. Pediatrics 1992;89:701-706.