February 2007 | Back to Table of Contents

Quality Rounds

Is This an Emergency? Don't Ask

By Scott D. Smith

Screening after-hours calls can put patients at risk.

After being thrown from a horse, a woman called a Denver, Colorado, family practice clinic in the early morning hours complaining of ankle pain.

When the operator from the answering service who took the call asked if it was an emergency, the woman said she didn’t think so and was told to call back during office hours the next day. She was diagnosed with a distal fibular fracture, and although the woman suffered no permanent damage, “she went on hobbling around for a day on a broken leg,” says David Hildebrandt, Ph.D., an associate professor in the University of Minnesota’s Mankato Family Residency Program and a psychologist at ISJ Clinic-EastRidge.

The case is an example of a troubling trend Hildebrandt saw among Denver-area primary care clinics. Before joining the University of Minnesota in 2005, he spent several years at the University of Colorado studying why patients make after-hours calls to their clinics and how clinics respond to those calls. Hildebrandt has published four papers on the subject since 2002, the most recent appearing in the September/October 2006 issue of the Journal of the American Board of Family Medicine.

About two-thirds of the 91 primary care offices he surveyed used after-hours answering services that employed nonmedical professionals who asked patients whether their problem was an emergency requiring notification of the physician on call.

He found that approximately 90 percent of callers said they considered their problem an emergency and were routed to a physician. The other 10 percent who said their problem was not were told to call back during business hours or that their information would be passed along to office staff the next day.

Callers at Risk
Hildebrandt’s most recent research suggests that using nonmedical staff to screen calls can be harmful to patients. For the study that was published last fall, he analyzed 4,949 calls handled by a Denver family medicine residency office’s answering service between April 2000 and March 2001. The service did not use medical staff to screen calls. About half the calls were clinical in nature and the rest were inquiries about bills, appointments, or other matters. Of the clinical calls, 288 were not forwarded to the physician on call.

After examining the medical records of 119 of those patients, Hildebrandt found that more than one-quarter of the diverted callers experienced ongoing pain and discomfort, 3 percent suffered harm, and 8 percent required a subsequent emergency room or office visit or a medication change.

He tells of a 21-year-old pregnant woman who called because of leaking amniotic fluid but said her situation wasn’t an emergency. She suffered nausea and pain for three days before being taken by ambulance to the hospital. Other diverted callers complained of chest pain—a possible sign of a heart attack—and symptoms that could have indicated suicidal ideation.

“The major issue is that if patients don’t get to talk to a medical person, there is a risk that they will be harmed,” Hildebrandt says.

Changing Habits
For the past few years, Hildebrandt has been pushing for medical practices to stop screening clinical calls by asking patients if it’s an emergency or if they need to speak with the doctor. Instead, every caller with a clinical question should get to speak with a medical professional, such as a nurse or a doctor.

He points out that having all patients with a clinical question who use the after-hours service talk to a nurse or physician is a small price to pay compared with that patient spending the night in pain or possibly suffering the consequences of an illness or injury that may be more serious than thought.

Denise Waldoch, R.N., Park Nicollet Health Services’ telephone triage project specialist, says relying on patients to diagnose the severity of their problem is a mistake and a liability risk. For example, she received a call several years ago from a mother who said her infant had mild shortness of breath. Waldoch had the mother place the phone next to the child’s mouth. “I heard this horrible breathing and told her to call 911 immediately,” Waldoch recalls. Instead, the mother drove the child to the hospital. By the time they arrived, the infant was barely breathing.

In September, Hildebrandt randomly called about 35 practices in urban areas in Florida, New York, Ohio, Kansas, Arizona, California, and Washington and found that 43 percent of them relied on answering services and that 86 percent left it up to the patient or answering service personnel to decide whether the situation was an emergency.

In general, he has found services that ask such questions are most often used by mid-sized practices, those with five to 10 physicians. Large organizations such as Park Nicollet and Mayo Health System, which owns the clinic at which Hildebrandt practices, tend to have systems in which nurses use established protocols to triage after-hours calls. Solo practitioners or doctors with only one or two partners often answer all of their patient calls.

Hildebrandt says with clinics fielding 2 million to 5 million after-hours calls a year on average, the practice of letting patients decide if they’re facing an emergency could place thousands of them in harm’s way each year and even cause some deaths.

He says physicians can make a simple phone call to their answering service and ask them to stop the practice, but it isn’t happening as often as he would like. After completing his study of the Denver clinics, Hildebrandt sent a letter to 15 practices alerting them to his findings and urging them to drop the screening question. Only three had done so when he checked back eight weeks later. “Just telling a doctor something is a problem doesn’t mean they’ll change,” he says.

Hildebrandt is applying for a grant from the National Institutes of Health to find the most effective ways to stop the practice. He says correcting the problem isn’t a “cure for cancer,” but it’s just the sort of thing that needs to be weeded out of health care. “The bottom line is that it doesn’t mean many more calls [for a doctor] … maybe one or two a night, and the pay-off is that these couple of patients each night don’t end up being put at risk,” he says. MM

Scott Smith is a staff writer for Minnesota Medicine.