An average pediatric office receives dozens of calls every day. Many are requests for appointments, referrals, letters for school, or prescription refills. Others are for nurse or physician advice. It is important that when parents call regarding ill children, practices have a triage system in place to ensure that patients receive the appropriate level of care (office, emergency department [ED], home care) and are seen in a time frame appropriate for their medical condition (immediately, same day, within 3 days). This article describes how a mobile application, a “web widget,” and an office triage support tool can expedite and improve your existing office triage capabilities.
Call centers vs office triage
Many pediatricians assign after-hours calls to a pediatric call center to ensure that parents concerned about their ill children receive accurate recommendations. These calls are recorded for quality purposes, and are staffed by pediatric nurses who utilize standardized telephone triage protocols. As discussed in last month’s article “Pediatric call centers fast-track urgent care” (Contemporary Pediatrics, April 2017), about 25% of after-hours triage calls result in the recommendation that the patient be seen in an ED; 50% are assigned to receive home care; and the remainder are seen in the physician’s office the next day or within a few days.
During office hours, approximately 50% of calls are for appointments, 30% of calls request nurse triage, and the remaining 20% request prescription refills, health forms, referrals, and so on. (Source: Greenwood Pediatrics and Advanced Pediatrics, Denver, Colorado). Keep in mind that most practices train receptionists to ask office nurses to triage certain calls before an appointment is made. These would involve young infants with fever; children with any trouble breathing; possible dehydration; seizures; injuries; or head trauma.
Office triage nurses will log the call as a phone message in the practice’s electronic health record (EHR), detailing the symptom or symptoms that concern the parent. They will use their telephone triage protocol book to quickly locate the appropriate protocol, and determine and document the patient disposition and the protocol or protocols used. Prudent nurses will place follow-up calls if home advice is given or if the patient is sent elsewhere for urgent evaluation. The Table lists the most common triage protocols used in the office environment in order of decreasing frequency.
Following triage by an office nurse (Figure), 57% of patients need just home-care advice; 21% are seen the same day; 16% are seen within 3 days; 3% are sent to the ED or urgent care; and just 0.1% are told to call 911. The remainder are given other dispositions (seen in office within few weeks, call specialist, call dentist). Although this office triage is sometimes time consuming, it is the best method to identify the level of care needed for the child of a concerned parent. This is not only good care, but it also reduces liability of the practice.
Using tech to self-triage
In this tech-savvy age, parents would prefer not to be placed on hold or wait for a nurse to return a triage call. Instead, practices can educate parents to download and use an inexpensive application or log onto the practice website to use a web widget to perform their own triage. Both the application and the web widget were developed by Barton Schmitt, MD, to facilitate triage for worried parents. These are based on his well-established triage protocols that have been used by call centers and pediatric practices for decades.
The Pediatric SymptomMD app can be downloaded for just $2.99 for all mobile devices (see “Top 10 apps for pediatrics,” Contemporary Pediatrics, February 2017). A free customized version of the app may be available from a children’s hospital in your area. The app provides triage and advice information derived from Schmitt’s telephone protocols, and details when to seek medical assistance and where and when parents should obtain care. It is easy to use and quickly advises parents whether they should call for an appointment, seek care elsewhere, or care for their child at home. The app also provides dosing advice for common over-the-counter medications. It is good practice to take every opportunity at well and ill visits to recommend that parents download the application and to demonstrate its use as well. (For a demonstration of this application, go to medgizmos.com/2017/01/15/pediatric-symptommd.)
An alternative to the smartphone triage application is the Symptom Checker Web Widget that can be easily integrated into your practice website. This is a great investment at $96 per provider per year when purchased directly from Self Care Decisions (Windsor, Colorado), and it gives the same triage information as that available in the mobile application. Parents can use the tool to quickly identify their child’s symptom based on body area. A few clicks later, the parent is advised where and when the child should be seen. If home care is advised, detailed instructions are provided. Dan Feiten, a pediatrician in Denver, Colorado, performed an automated exit survey of 2600 users of the Symptom Checker on his practice website in 2012. The survey indicated that:
· 62% of parents said the content saved them a call/visit to their doctor.
· 53% said they were going to call their doctor but no longer needed to contact the doctor’s office.
· 94% said they preferred to get this information from the practice website.
Use tech to improve nurse triage
It is very important that office nurses diligently use protocols when triaging calls and carefully document each encounter. As most practices use EHRs, nurses are needed to document within the patient’s electronic chart. Many EHRs are labor intensive, and electronic notes often take longer to complete compared with a simple handwritten note.
A solution to this problem is an online version of Schmitt’s protocols called ClearTriage. The ClearTriage decision-support tool is subscription based and is quite affordable for $49 per month per concurrent user. When a call is transferred to the office triage nurse, the intake information is quickly entered into ClearTriage. Based on the conversation between nurse and parent, the nurse then selects the appropriate protocol to use. With a minimum of clicks, the nurse provides the parent with disposition and advice information. The nurse can even e-mail or text the information to the parent along with relevant handouts. Best of all, the triage call note can be copied and pasted into any EHR, sparing the nurse a lot of unneeded typing. A demonstration of the ClearTriage decision-support tool by David Schmitt is now available online at www.medgizmos.com.
Pediatric offices should have an effective office triage system in place. Pediatricians who choose to recommend an inexpensive mobile application or use a symptom-checker web widget will benefit from fewer calls as well as have parents who are more confident in caring for their children. Using an online support tool also can improve triage consistency and expedite documentation of triage calls while supporting the patient-centered medical home.