Prioritizing Telephone Calls

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Prioritizing Telephone Calls

​The goals for quality management of telephone care in an office setting are to:
  1. Protect Patient Safety
  2. Prevent Under Referral
  3. Reduce Medical Liability
  4. Increase Efficiency
​​

Telephone care carries a great deal of risk. One of the most common risk scenarios in pediatric lawsuits involves a parent calling with a child with a serious medical condition whose care is delayed, resulting in harm to the patient. While this possibility exists once the patient has been placed in direct contact with a physician or triage nurse, training and well-designed telephone care protocols help to minimize this scenario. Yet the possibility for risk and patient harm also exists earlier in the process – with delay between the time of the initial call, and contact between the parent and a trained triager.

Safe call prioritization in an office setting begins with examining the process by which an office routes calls. Automated phone systems, while decreasing busy signals and hold times, offer risk of delayed response times. Patients may not know what constitutes an emergency and leave a non-emergent message to be returned later. Yet by leaving a message, duty to treat may be created, at which time the MD becomes liable for delay in response. Patients must also be given expectations of when their calls will be returned, have access to a receptionist (at least) at all times, and be told to call back if they do not receive a call back in a given time frame, or if symptoms worsen.

Once a receptionist is reached, there remains great opportunity for risk. Clerical staff and medical assistants, by their training and scope, do not have skills to assess and triage patient calls. At this point, all offices should have a defined workflow for immediate access to the provider (MD, NP, PA) or registered nurse. If immediate access cannot be secured, a "red flag list" can be used as a reference for non-clinical personnel to identify chief complaints in which EMS should be activated. An example of a red flag list is included below. Although the list may provide immediate guidance, caution must be executed as lists can never include all potentially life threatening situations. Red flag lists may vary depending upon clinical areas and access to emergency services and immediate clinical triage. An office's red flag list should be well known to both clinical and non-clinical personnel and reviewed on a consistent basis (e.g. quarterly, semi-annually, or annually). NOTE: It is always preferred that clinical personnel manage all calls that involve potential or actual life-threatening situations.

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Additional AAP Telephone Care Resources

Pediatric Telephone Protocols, 15th Edition
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.​​​​​

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911 S​ymptoms (Refer to 911 or Physician Immediately)

Central Nervous System:

​Actively seizing
Unconscious
Change in mental status
Acute loss of neurological function
Can't speak
Can't move a body part
Can't see, etc.

Respiratory:

Not breathing
Severe difficulty breathing
Choking (can't talk or cry)
Bluish lips or tongue AND difficulty breathing
Swollen tongue
Anaphylaxis
Possible foreign body in airway AND difficulty breathing

Cardiac:

Severe chest pain
Any chest pain associated with any of the following: Left arm pain, Sweating, Nausea,
Difficulty breathing

Trauma:

Uncontrollable and excessive bleeding
Unattached body part (except fingernail or tooth)
Trauma to neck or eye

Psychiatric:

Suicidal or homicidal intent

Gastrointestinal:

Vomiting large amounts of blood repeatedly

OB/Gyn:

Vaginal bleeding that is excessive and continuous (more than a heavy period)

Skin:

Blue or purple rash associated with a fever

Genitourinary:

Testicular pain that is severe and associated with swelling or discoloration​

Emergent Calls (Transferred without delay to RN or Provider):

Trouble breathing (eg: stridor, croup, or wheezing)
Fever greater than 105 degrees
Any fever in child less than 3 mo.
Asthma or any trouble breathing
Blue/purple rash
Trauma
Severe pain

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

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