After Hours Telephone Care

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After Hours Telephone Care
​​Each pediatric practice must evaluate how best to manage after-hours calls. In most cases, the choices will include a traditional telephone answering service and a professional after-hours call center.

​Professiona​l After-hours Call Centers

Professional after-hours call centers are dedicated specifically to medical (and often pediatrics-only) callers and staffed with registered nurses and other clinical staff who are able to screen with a high level of medical competence using evidence-based protocols for triage and advice.

​The advantages to using a professional after-hours call center are as follows: safe management of symptom-based calls to achieve appropriate level of care; standardized documentation that is more likely to be useful for both continuity of medical care and for medical-legal purposes; high acceptance by patients and families; and significantly decreased telephone time with patients/families for on-call physicians. 

After-hours call centers provide professional representation for the pediatric practice. Therefore, inquiry should be made about the professional scope of the individuals answering calls, how they are trained and supervised, if they are certified, and which triage manuals and software are being used. The name and degree of participation by the supervising physician should also be explored. Inquiring about the volume of calls handled by the center, the number of physicians it serves, and its formal affiliations with insurers and hospitals may also be useful. Both the service itself and its professional employees should be licensed in your state and should carry their own liability insurance. The malpractice insurer for the pediatric practice and its participating healthcare plans should agree in writing that use of this outside provider for after-hours calls does not violate contractual agreements. It is strongly recommended that a practice physician should review triage protocols at regular intervals to be certain that they conform to practice recommendations and advice. Discrepancies should be noted and discussed with an appropriate call center representative. 

Additional AAP Telephone Care Resources

​Sample Office Policy​
A sample policy entitled, “After-Hours Phone Calls and Web Messaging” that can be customized for use in your practice. 

A go-to resource for telephone care triage, which covers a broad spectrum of caller concerns. 

Pediatric Nurse Telephone Triage
A decision-support tool that is a companion to Pediatric Telephone Protocols, and helps office staff deliver superior telephone advice. 

Breastfeeding Telephone Triage and Advice​
Resource to help nurses, lactation professionals, and other medical staff confidently advise breastfeeding mothers by phone.​​​​​​​​​​

Advertising Disclaimer

Traditional Telephone Answering Services

In most cases, telephone answering service personnel have no formal medical training and minimal medical knowledge. Their primary function is to relay messages accurately and in a timely fashion. However, informal triage of calls occurs when the operator must decide whether a physician should be contacted on an urgent basis.

Many practicing pediatricians continue to rely on traditional telephone answering services to screen after-hours patient calls for a number of reasons including: triage services are not available in all geographic areas; some physicians dislike delegating after-hours telephone responsibility to others; call centers may not be cost-effective for all practices; and some pediatricians believe that their patients may perceive a call center as impersonal or inconsistent with their practice style.

It is recommended that the telephone answering service agree to follow written instructions provided by practice physicians when informally triaging calls. The list should be short, avoid medical and technical terminology, and allow for over-screening of calls. Except in special circumstances, it is best not to list all of the conditions for which the physician would like to be called, e.g. trouble breathing, high fever, head trauma, etc. The list is too long to be practical and exclusions might create liability. An example of such instructions is given below: 

Unless you are otherwise notified, our physician will call in once every 90 minutes for non-urgent calls. However, there must be a way to expedite calls to the physician on call. The following are potential emergent situations: 

  • The caller believes the call is an emergency. (Best screening question: Is this call an emergency? or Do you feel frightened about the way your child looks or is acting?)
  • The caller believes the problem can't wait until the next call-in time. (Best screening question: The doctor will be calling in at 9 o'clock, but I can page her if you believe this problem can't wait.)
  • You (the service operator) believes the call is an emergency because of the type of complaint or because the caller seems very nervous. 
  • The caller has made multiple calls about the same problem. 
  • The patient is an infant less than 2 months of age who has fever or is acting sick.​

Important Fac​tors

Whether a professional after-hours call center or a traditional telephone answering service is chosen to screen calls, the pediatric practice should obtain basic information before a specific service is chosen. Reputation is important. A list of recommended providers can often be obtained from a local professional society or affiliate hospital and augmented with recommendations from colleagues. 

Before contacting a prospective call center or telephone service, prepare a set of policies that list your practice office hours and location, the usual sign-in and sign-out times of covering doctors, backup telephone numbers for each covering doctor, the usual procedure for retrieving non-urgent messages (e.g. calling-in every 90 minutes), the practice's preferred hospital for emergencies, and procedures to follow if a covering physician cannot be reached. This list should be used to discuss specific practice concerns and how they will be managed by that service. It can also be left on file for reference if that service is chosen. It is preferred that a service or center will be electronically connected and be accessible immediately or that the encounter can be faxed or transmitted to the physician on demand or when the clinic opens the following morning. The encounters should be reviewed promptly by a physician or registered nurse who is able to review and determine whether follow-up calls are needed. The log can then be maintained for office use and pertinent data can be entered into a patients chart. The chosen service or center must be HIPAA compliant and agree to sign an appropriate agreement of confidentiality. 

Other topics for discussion should include the number of call-screeners available; the usual waiting time before calls are answered; and contingency plans in the event of computer or telephone failure. Projected monthly charges based on the usual practice call volume should be reviewed at the time of this discussion.

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