The first call center was introduced in 1988 as a uniquely pediatric innovation. This month’s article presents a brief history of call centers, discusses their advantages, and describes how they will improve patient care.
Many pediatricians sleep well at night because they utilize call centers to respond to after-hours calls. The first call center was introduced in 1988 as a uniquely pediatric innovation. This month’s article presents a brief history of call centers, discusses their advantages, and describes how they will improve patient care.
In the mid-1970s, researchers affiliated with the Children’s Hospital Medical Center (now Boston Children’s Hospital) in Boston, Massachusetts, performed a feasibility study in which nonmedical “health assistants” used algorithms to refer patients for urgent care.1,2 Health assistant triage recommendations were compared with those made by emergency department (ED) physicians and nurses. In the study, 60% of callers were advised by health assistants to seek urgent care, compared with 44% of those who spoke directly with medical providers. Although the overreferral rate was striking, the study established that algorithms could be used effectively, even by nonmedical personnel. The researchers speculated that “call centers” could be developed similar to “poison centers” that were common at the time.2,3
The first pediatric call center was introduced in 1988 at the Children’s Hospital Colorado, Aurora, with 10 subscribing physicians, and in 4 years it grew to serve 92 pediatricians. Physicians were charged on a per call basis, initially $10 per call, later decreasing to $8.25 per call. For most physicians, payments to the call center were estimated to be about 1% of practice revenue. Nurses were trained to use telephone triage protocols4 developed by Barton Schmitt, MD (one of the authors of this article), to triage calls into 1 of 3 categories: 1) patient to be seen immediately; 2) patient to be seen next day; or 3) home advice only given.
Logs were reviewed regularly, and nurses continued to receive training to improve their triage abilities. In the first 4 years of the program, the call center managed a total of 107,938 calls. Fever, rash, vomiting, injury, earache, cough, diarrhea, sore throat, fussiness, and abdominal pain were the top 10 triaged complaints (in order of decreasing frequency). Twenty percent of these calls fell into the “immediate care” category; 28% were advised to be seen the next day; and 52% were given home care advice only. One percent of calls resulted in the patient being hospitalized.5
The call center continued to grow and serve an increasing number of Colorado pediatricians. During a 1-year survey conducted from 1999 to 2000, 141,922 calls were answered, representing over 1000 calls per enrolled pediatrician. Disposition rates changed little from those reported 11 years earlier, with 21 % of callers advised to be seen immediately, 45% given home care instructions, and 30% advised to follow up with their pediatricians the following day.6
Eventually, many healthcare systems and hospitals developed call centers that served adults as well as children, and today these call centers receive an equal number of calls regarding adults as well as children. Overwhelmingly, physicians, patients, hospitals, and insurance companies have been advocates because call centers ensure that medical care is provided in the most appropriate, most cost-effective location.
Traditionally, patients are overusers of ED services. The New England Healthcare Institute (NEHI), Cambridge, Massachusetts, estimated in 2010 that on average an ED visit costs $580 more than an office visit, and that 67 million, or about 56%, of 120 million annual ED visits were avoidable.7 The institute estimated that more than $38 billion is wasted each year from ED overuse. It posited that reduction in costs associated with these unnecessary ED visits, could be achieved by:
It is worth noting that 25% of patient calls to Children’s Hospital Colorado’s pediatric call center are from patients without a medical home. Also of note is that a recent study indicated that access to retail-based clinics did not result in a significant reduction in low-acuity ED visits.8
A follow-up study looked at the cost savings associated with recommendations made by the call center at Children’s Hospital Colorado during 2004. Researchers discovered that two-thirds of the cases in which parents reported initial intent to go to an ED or urgent care facility were not deemed “urgent” by nurse triage, whereas 15% of calls from parents who intended to stay home were triaged as “urgent.”9
Had the callers implemented their initial intentions, the cost to the healthcare system would have been more than $1 million. Had the recommendations that were made by the nurse advice line been heeded in every case, the cost to the healthcare system would have been $410,615 less than the intended services. This amount translated into a saving of $42.61 per call after expenses. The conclusion: Advice offered by call centers can save patients unnecessary healthcare costs and reduce ED overuse substantially.9
Do parents take the advice of call centers? To determine compliance rates as well as the frequency of underreferrals made by their call center, investigators affiliated with the Children’s Hospital Colorado reviewed more than 32,000 calls received from 1999 to 2003. At that time, recommendations were divided into 4 categories: urgent (visit within 4 hours); next day (>4 hours and within 24 hours); later visit (>24 hours); or home care (no visit). They discovered that compliance with urgent and home care calls was 74%, and compliance with next day recommendations was 44%. No deaths occurred within the week following the triage call and only 1 case per 599 resulted in hospitalization.10 In another study, there was a 90% agreement between ED referrals made by nurses and the ED physicians who evaluated the patients.11
Additionally, the goal of the call center at Children’s Hospital Colorado was to achieve 0% ED underreferrals, and to always err on the side of caution and have no higher than a 10% overreferral rate. The only way that has been shown to improve upon call center triage ED referral rates is to have second-level physician triage. Doing so can reduce call center referrals to EDs from about 20% to 10%.12 The reason is that physicians are familiar with patients and parents in their practices and this familiarity can guide recommendations. Frequently, physicians postpone seeing the patient until the next morning.
The quality of call centers depends on multiple factors. The training of triage nurses is a key element, as is the accurate logging of calls with recommendations, in addition to ongoing quality assurance making sure that calls are triaged correctly. The call center at Children’s Hospital Colorado has a monthly targeted review as part of its ongoing quality assurance program. All calls are recorded and are available for review. A rotation through the call center is an integral part of the pediatric resident training. The protocols are evidence based, reflect current opinion of experts in pediatric care, follow current national guidelines, and are reviewed and updated every year. Since it opened in 1988, the call center has logged over 2 million calls, and there have been no adverse outcomes during this time.
As of 2016, there were over 400 call centers using the Smith-Thompson Clinical Content (STCC) protocols with over 20 million calls logged every year.
Canada has a provincial call center system. Many hospitals have their own call center, and many children’s hospitals nationwide provide nurse triage services. There are independent call centers, and some health insurers provide call center services.
Providers should be aware that call center services are not created equal. Many centers that provide triage for pediatric patients do not employ pediatric nurses. Call centers usually charge less than $1 per minute, with most calls lasting less than 10 minutes. Many integrated health systems facilitate patient scheduling so nurses can access physician office schedules, and many hospitals are expanding their services to proactively counsel patients discharged from the hospital to reduce readmission rates.
Call center usage is changing (see Table). Tech-savvy parents and patients use multiple resources to self-triage. Call centers can review videos and images sent by patients and routinely send e-mail instructions to facilitate compliance. It has been shown that access to a parent advice book can substantially reduce calls to triage services. In 1 study, distribution of a parent advice book reduced sick visits to health maintenance organization (HMO)-affiliated medical practices by 23%, nurse advice calls by 24%, and prescriptions by 26%.13 When a healthcare system distributed and promoted the use of a triage app to its members in 2013, ED utilization dropped by 39%.14
In the opinion of the authors, call centers will continue to evolve. Triage will eventually employ telehealth video technology to improve triage accuracy as well as compliance. It is also possible to recruit call centers to assist with care coordination of children with chronic or complex diseases. In addition, nurses or medical assistants, working out of a call center, can assist with many of the chores that overburden physicians today (prior authorizations, requests for routine forms/letters, and more), reducing burnout rates while facilitating access to an “integrated medical home.”
Keep watching this space because next month’s Peds v2.0 will discuss how you can use your office triage system to improve efficiency.
1. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics. 1979;64(5):553-557.
2. Levy JC, Rosekrans J, Lamb GA, Friedman M, Kaplan D, Strasser P. Development and field testing of protocols for the management of pediatric telephone calls: protocols for pediatric telephone calls. Pediatrics. 1979;64(5):558-563.
3. Fosarelli P, Schmitt B. Telephone dissatisfaction in pediatric practice: Denver and Baltimore. Pediatrics. 1987;80(1):28-31.
4. Schmitt BD. Pediatric Telephone Advice: Guidelines for the Health Care Provided on Telephone Triage and Office Management of Common Childhood Symptoms. Boston, MA: Little Brown & Co; 1980.
5. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics. 1993;92(5):670-679.
6. Belman S, Chandramouli V, Schmitt B, Polle SR, Hegarty T, Kempe A. An assessment of pediatric after-hours telephone care: a 1-year experience. Arch Pediatr Adolesc Med. 2005;159(2):145-149.
7. New England Healthcare Institute (NEHI). How Many More Studies Will It Take? A Collection of Evidence That Our Health Care System Can Do Better. Cambridge, MA: New England Healthcare Institute (NEHI); 2008. Available at: http://www.nehi.net/writable/publication_files/file/how_many_more_studies_will_it_take_introduction.pdf. Accessed March 13, 2017.
8. Martsolf G, Fingar KR, Coffey R, et al. Association between the opening of retail clinics and low-acuity emergency department visits. Ann Emerg Med. November 4, 2016. Epub ahead of print.
9. Bunik M, Glazner JE, Chandramouli V, Emsermann CB, Hegarty T, Kempe A. Pediatric telephone call centers: how do they affect health care use and costs? Pediatrics. 2007;119(2):e305-e313.
10. Kempe A, Bunik M, Ellis J, et al. How safe is triage by an after-hours telephone call center? Pediatrics. 2006;118(2):457-463.
11. Kempe A, Dempsey C, Whitefield J, Bothner J, MacKenzie T, Poole A. Appropriateness of urgent referrals by nurses at a hospital-based pediatric call center. Arch Pediatr Adolesc Med. 2000;154(4):355-360.
12. Kempe A, Dempsey C, Hegarty T, Frei N, Chandramouli V, Poole SR. Reducing after-hours referrals by an after-hours call center with second-level physician triage. Pediatrics. 2000;106(1 pt 2):226-230.
13. France EK, Selna MJ, Lyons EE, Beck AL, Calonge BN. Effect of a pediatric self-care book on utilization of services in a group model HMO. Clin Pediatr (Phila). 1999;38(12);709-715.
14. Krames StayWell. Physicians Plus Insurance: Growing a health care brand with mobile engagement. Newsletter. Published February 2013.
15. Schmitt BD. Pediatric Telephone Protocols: Office Version. 15th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016.
16. Thompson DA. Adult Telephone Protocols: Office Version. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He is CEO of Medgizmos.com, a medical technology review site for primary care physicians. Dr Schmitt is medical director, Pediatric Call Center, Children’s Hospital Colorado, Aurora, and author of Pediatric Telephone Advice and Telephone Triage Protocols. He is also a past member of Contemporary Pediatrics’ Editorial Advisory Board.