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When an elderly man came to the ED at Bay Pines (FL) VA Medical Center complaining of atypical chest pain and shortness of breath, he left without being seen. "He decided he couldn’t stay because his wife was ill at home. He didn’t even stay for the lab work," recalls Susan Schaeffer, RN, the ED’s telephone care program nurse.
When the patient was called the following morning, the chest pain had intensified. "He was very worried about his wife, and it was arranged for a neighbor to be with her. He agreed to come back in and had a massive myocardial infarction with a troponin level of 34," Schaeffer reports.
Making a brief follow-up telephone call potentially can save a patient’s life, she notes. "The phone calls help encourage patients to get the care they need," she says. (See "Tips for follow-up phone calls," "Make follow-up calls to these patients," and "3 ways to track follow-up calls," in this issue.) Here are ways to provide effective telephone follow-up with patients:
• Have a specific nurse make follow-up calls.
At Bay Pines, a nurse works Monday through Friday to contact patients who left the ED without being seen, says Marcia Berry, RN, BSN, nurse manager for ED, triage, and occupational health. If possible, telephone follow-up should not be combined with ED clinical responsibilities, advises Berry. "When the nurse is not here, follow-up is missed on some patients, since it’s everyone’s second priority to do that," she acknowledges. If other things come up, that seems to be the first thing to go."
After the call, the nurse documents why the patient came into the ED and why he or she left without being seen, says Berry. "Most of the time, we found it’s because the patient does not view their illness as seriously as it’s perceived by the medical staff," she notes. It also helps if the nurse doing the follow-up calls is impartial, says Berry. "ED staff tend to be more defensive and don’t have an objective view," she says. "Also, if the patient knows they are talking to an ED staff member, they may be reluctant to give an honest response."
The person doing the call-back should be a good listener, non-argumentative, and experienced in giving advice over the phone. "A skilled triage nurse is probably the best person to do this," advises Laura J. Roepe, RN, MA, CEN, quality systems analyst for United States Surgical/Tyco Healthcare and former administrative manager of the ED at Norwalk (CT) Hospital.
However, this isn’t always feasible because of the time it takes to do the call-backs and the volume of patients being triaged, she acknowledges. In this case, Roepe recommends assigning a nurse on light duty, delegating the call-backs as an additional charge nurse duty, or providing incentives such as extra pay for a nurse to make the call-backs.
• Make sure the episode is resolved.
Sometimes the problem the patient came to the ED with is still present or has intensified, says Schaeffer. "If the patient came in because of chest pain, and decided to leave before being admitted to the coronary unit, they may still be having pain," she notes. Many patients are reluctant to come back to the ED after signing out, Schaeffer says. "If so, we can educate the patient, and encourage them to ask someone to drive them in or call 911," she says.
• Consider patient satisfaction.
You may be surprised at how patients react when you call, says Schaeffer. "In general, the patient’s mouth drops when you identify yourself and tell them that you are calling as follow-up and just want to find out how they are doing," she says. "I think it is one of the best ways to let them know that we do care."
Telephone follow-up is a boon for public relations, says Roepe. "The message of we care’ is instantly generated just by the phone call," she adds. It’s also a good way to find out if patients are happy with the care they received in the ED, especially from individuals who may not take the time to complete a written survey, notes Roepe. "Virtually everyone I have called back was happy to have the chance to talk to someone from the hospital, get questions answered, and if necessary, vent a little about the care they received," she says.
Even patients who leave without being seen are responsive, she reports. "Many take up the offer of returning that day to try again’ because they now have a name they can drop to expedite the process," she says.
• Educate patients.
Some patients admit to Schaeffer that they were out of a drug and thought coming to the ED was the best way to get it. "They may say they have a headache, but it wasn’t urgent, and they got tired of waiting so they left," she says. "I can educate them and explain that a better way would have been to call the pharmacy."
For more information, contact:
• Marcia Berry, RN, BSN, Bay Pines VA Medical Center, PO Box 5005, Bay Pines, FL 33744. Telephone: (727) 398-6661. Fax: (727) 398-9557.
• Laura J. Roepe, RN, MA, CEN, United States Surgical/Tyco Healthcare, 195 McDermott Road, North Haven, CT 06473. Telephone: (203) 492-6334. Fax: (203) 492-6661.
• Susan Schaeffer, RN, Bay Pines VA Medical Center, PO Box 5005, Bay Pines, FL 33744. Telephone: (727) 398-6661 ext. 7437. Fax: (727) 398-9557.