Emergency department telephone advice

Daniel M Fatovich, Ian G Jacobs, Jill P McCance, Kerry L Sidney and Rod J White

MJA 1998; 169: 143-146
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Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
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Abstract	Objective: To evaluate telephone advice given in an emergency department. Design: Prospective, observational study. Setting: A community-based emergency department in a semi-rural/outer metropolitan setting, between August and November 1995. Participants: All people telephoning the emergency department for medical advice. Methods: Details of all calls, callers and patients were recorded. Within 72 hours, a follow-up call was initiated seeking replies to a series of standardised questions. Main outcome measures: Number, timing and duration of calls; appropriateness of the advice given; compliance with the advice; and callers' satisfaction with the service. Results: Over the four-month period, 1682 calls were received, 58% between 4 pm and midnight. There were 33 telephone calls per 100 emergency department attendances. The mean call duration was 3.9 minutes (range, 0.25-25 minutes); 49% of patients were less than 14 years old, and 72% of callers phoned because of spontaneous illness. The advice given was considered inappropriate in only 1.4% of calls. Follow-up calls were made to 1132 people (67%), revealing a non-compliance rate of only 6.9% and a high level of caller satisfaction, with 99% of callers affirming a need for such a service. Conclusions: The provision of telephone advice by emergency department staff is rated highly by the community and compliance with the advice is strong. Paediatric problems, arising as a result of spontaneous illness, predominate and there is a large bias towards after-hours use of the service. Experienced staff provide better advice.
Introduction	Emergency department (ED) staff are frequently telephoned by members of the community who seek medical advice. Little is known about who calls and why, how much professional time is required, what problems people call about and the quality of the advice given.1 In particular, caller compliance has seldom been assessed. This study was conducted to provide a detailed analysis of emergency department telephone advice. A prospective, observational study, it was undertaken at Swan District Hospital, which is situated 20 km northeast of the central business district of Perth. The hospital has 148 beds, is community based and over 15 000 patients attend its ED each year. It serves a population of over 142 000 residents in a metropolitan and semi-rural setting. There are approximately 160 general practitioners in the area who provide some after-hours care. The catchment population was more socioeconomically disadvantaged than that of the metropolitan area.
Methods
Data collection	The survey took place from 1 August to 30 November 1995. All telephone calls from people seeking medical advice were answered by an ED registered nurse who was responsible for triage and later reviewed. Details of the call, including the date, time, patient's name, age and sex, caller's name, relationship of the caller to the patient, patient's telephone number, presenting problem and advice given, were recorded on a telephone advice form during the call. Each call was timed using a stopwatch and problems were divided into four categories: spontaneous illness, injury, poisoning, and drug-related.
Evaluation of the calls	To establish the quality and appropriateness of the telephone advice given, each completed telephone advice form was assessed independently by at least two authors. Disputes were settled by a third author. The authors deemed the advice to be either appropriate or inappropriate and, in cases where the advice was considered to be inappropriate, defined it as potentially life threatening, at risk of causing serious sequelae or not serious.
Caller feedback	At the completion of each call, permission was sought for a follow-up call to determine the caller's response to the advice given. Where permission was given, a research nurse telephoned the caller within 72 hours of the initial call. The nurse asked each caller how he/she had acted upon the advice, how helpful the advice had been, if the caller had sought advice elsewhere, if he/she had used an ambulance when advised, and his/her overall perception of the telephone advice service. Callers were also encouraged to freely make comments about the service.
Statistical analysis	Data were analysed using the Statistical Package for Social Sciences (SPSS).2
Ethical approval	Approval for the study was obtained from the Ethics Committee of the Swan Area Health Service.
Results
Number, timing and content of calls	During the four-month period 1682 calls were received. The average number of calls per day was 14 (range, 3-32). Given that there were 5127 attendances at the ED during the same period, the ratio of calls to ED attendances was 1:3 (33 calls per 100 attendances). The mean age of the patients was 22 years (range, 1 week-95 years), although 49% were under 14 years (Figure 1). Fifty-five percent of patients were female. Comparison of the age and sex distribution of patients who called the telephone advice service with that of patients who attended the ED showed that callers were more likely to be younger and female (Box). Almost a quarter (24%) of all calls were received on Sunday, 17% were received on Saturday, and Monday was the busiest weekday (Figure 2). Calls between 4 pm and midnight constituted 58% of all calls received (Figure 3). The mean call duration was 3.9 minutes (± 2.5 minutes), with the longest call taking 25 minutes (allowing also for a brief request for a follow-up call). The patient was the caller in 32% of cases. Where the caller was not the patient, 63% and 17% of calls, respectively, were made by a parent or spouse. Eighty-two percent of calls were from the Swan Area Health Service catchment area. The others were from the city of Perth and its surrounds. Spontaneously occurring illness accounted for 72% of calls (1175). The most common problems were fever in children, pain (especially earache in children), and shortness of breath. A further 22% of calls were for injuries.
Advice given	Advice was considered inappropriate in 23 cases (1.4%). Of these, 11 (48%) were assessed as potentially life threatening (eg, a 42-year-old man with chest pain who had previously had a coronary angioplasty was not advised to attend hospital by ambulance). Four (17%) were considered at possible risk of serious sequelae (eg, an 18-month-old child with a two-week history of lethargy, fever and vomiting was not advised to see a doctor). Staff with less than two years' relevant ED experience were responsible for 78% of the inappropriate advice given (18 of 23 calls) and 100% of potentially life-threatening advice. No advice was given in 97 cases (6%) as the caller rang merely to inform the ED of their impending arrival. Only one call was prompted by an imminently life-threatening situation (a 40-year-old man with insulin-dependent diabetes who could not be roused by the caller). The patient was making a "funny noise breathing" and the caller was unable to give him sugar. The caller was correctly advised to ring for an ambulance. A Dextrostix test performed by ambulance officers indicated a low blood sugar level of 1.4 mmol/L. They administered glucagon intramuscularly, which raised his blood sugar level to 4.2 mmol/L.
Caller feedback	A total of 1132 patients (67%) consented to follow-up. Of these, 42% had previously used the service and 89% considered the advice to be useful or very useful. Almost a third (30%) had sought advice elsewhere before calling the ED, 43% of these from their general practitioner. The level of compliance with advice was established in 1205 cases (72%). This included 73 cases where the caller later attended the ED and compliance was able to be determined from the medical record. Eighty-three people (6.9%) did not comply with the advice received, including 34 who were advised to call an ambulance but failed to do so. The main reasons for this were the anticipated cost of the ambulance journey, the caller's perception that the problem did not require an ambulance (despite being advised to call one), and the belief that travelling to the ED would be faster by private transport. Other reasons for non-compliance ranged from lack of transport and unwillingness to wait, to simple refusal to follow the advice because the caller believed that they knew better. About a quarter of callers (26%) subsequently attended their general practitioner, and 13% elected to monitor their problem. Five hundred and ninety-nine patients (50%) attended an ED, 92% attending the Swan District Hospital ED. The distribution of problems which warranted attendance was similar to that of the problems which had prompted the original call. Of those attending an ED, 94 patients (16%) were admitted to hospital. Each caller who was followed up was asked to rate the telephone advice service on a scale of one to 10, with 10 being "excellent". The mean score was 8.9, with only 1.5% of respondents giving a score of less than five. There was overwhelming support for a telephone advice service, with 99% of those contacted affirming the need. The majority of respondents (86%) also indicated that they would be disappointed if the telephone advice service were discontinued.
Discussion	Throughout the world, it is common practice for ED staff to provide telephone advice. This is almost unavoidable because patients require access to health information and medical advice at all times. Health authorities need to consider this when planning health services. The American College of Emergency Physicians3 and the British Association of Emergency Medicine4 have position statements on giving telephone advice, and the British government has announced plans for a 24-hour patient helpline staffed by nurses.5 Pilot schemes have already commenced. We found that the ED in our study received 33 telephone calls for advice per 100 ED attendances. This is consistent with the results of a survey of 130 Australian EDs which reported a national figure of 28 calls per 100 attendances.6 The same study calculated an annual volume of almost 1.2 million ED telephone advice calls (almost two every minute) and found that two-thirds of Australian EDs provide telephone advice, with rural EDs more likely to provide this service than metropolitan EDs. This may reflect rural isolation from medical care. Some metropolitan hospitals have developed specialised advice lines for people with sick children.7 An unavoidable limitation of this study was that a third of callers were lost to follow-up. Seasonal factors may have been another source of bias. Other limitations were that the social desirability of giving an acceptable answer may have contributed to the degree of compliance reported, and that the performance of the nurses giving the advice may have been influenced by the fact that a study was being undertaken (the "Hawthorne effect"). Most Australian households have a telephone and are aware of their nearest public hospital: in our consumer- oriented society, it is little wonder that EDs are frequently telephoned for advice.8 The bias towards after-hours use probably reflects a lack of alternative resources. Previous studies have concluded that ED telephone advice is inexpensive, safe, allows public access to health information and encourages consultation with a doctor as appropriate.9 According to Verdile et al,10 telephone advice should be considered an outreach program of the ED. However, EDs are rarely funded to provide this service. Our finding of a 93.1% compliance rate is high, but consistent with the only other study of compliance. Egleston et al9 found that 99 of 104 callers (95.2%) were compliant with the telephone advice. The commonest scenario in which advice was not followed involved the use of an ambulance. This result should be considered by providers of prehospital care. It was apparent from our study that people telephoned the ED not just for medical advice, but also as a last resort in social crises. These included problems ranging from domestic violence and child abuse to suicide and social isolation. The advice included direction of callers to appropriate community resources, advising medical assessment or simply providing empathy. At times, telephoning the emergency department may be the only option of which the caller is aware. This reflects the ED's function as society's healthcare "safety net" 24 hours a day, seven days a week. Most calls lasting over 15 minutes were in this category. The longest call, which lasted 25 minutes, was from a woman who was anxious about her five-month-old baby being difficult to settle due to "colic" after having been vaccinated the previous day. The call was made during a quiet period in the ED and the nurse who took it took the time to listen and empathise. Nurses have traditionally been, and are described in other reports as, the predominant ED staff members responsible for answering medical advice telephone calls. Often, however, nurse training in this important component of ED work is absent. Protocols for telephone triage have been assessed and found to be effective.11,12 The protocols have checklists which assist the user in gathering essential data from the caller, provide built-in guidelines for patient management and facilitate documentation.10 Such protocols should be standardised as the literature reveals that the quality of medical advice varies and that inappropriate advice can be harmful. Aitken et al13 found the advice to be inadequate in 16 of 36 institutions assessed when given a theoretical case of a 5-week-old infant with a fever of 38.5¡C. When Verdile et al10 surveyed EDs using a scenario that may have been myocardial ischaemia, only 4 of 46 respondents recommended that the patient be brought to the nearest ED by ambulance. Their findings indicate that the telephone advice given by some EDs is inconsistent and may be inadequate to the point of jeopardising the health of those seeking advice. Medicolegal concerns are frequently raised in relation to telephone advice, although an estimate of the exact magnitude of the problem of litigation is difficult to ascertain.10 However, it is possible that hospitals could be held accountable for giving either poor advice or refusing to help. The literature suggests that, although questioning a caller about a problem is acceptable, once any advice is offered over the telephone the ED staff member has assumed a legal obligation to the caller and is responsible for any advice given.14 Hence, it is important to have guidelines and to document all calls. Telephone advice is a difficult skill to perform well but one that is important to master. The consequences of error can be serious, and hence the use of experienced and trained staff who are aware of the limitations and ramifications of providing the service is mandatory. A basic rule is that diagnosis via the telephone is not possible and that the best advice is to recommend a face-to-face consultation. With common sense, the proper use of the telephone can both facilitate patient care and maximise the available human resources. It fulfils a genuine community need and helps promote better community relations. We found that the provision of telephone advice by ED staff is rated highly by the community and that compliance with the advice is strong. Calls regarding children with spontaneous illnesses predominate, and there is a strong bias towards after-hours use of the service. Experienced nursing staff provide better advice. The provision of telephone advice is an under-recognised function of the emergency department of which healthcare planners should be aware.
Acknowledgements	This study was made possible by a research grant from the Commonwealth Department of Human Services and Health (Ambulatory Care Research and Pilot Program) and the support of the Health Department of Western Australia, Health System Policy Branch. The authors are grateful to all ED staff who participated, especially Sheila Penman, RN.
References	Knowles PJ, Cummins RO. Emergency department medical advice calls: who calls and why? J Emerg Nurs 1984; 10: 283-286. SPSS Inc, release 6 [computer program]. Chicago,Illinois: SPSS, 1993. American College of Emergency Physicians. Providing telephone advice from the emergency department. Ann Emerg Med 1990; 19: 600. British Association for Emergency Medicine Clinical Services Committee. Guidelines on the handling of telephone enquiries in emergency departments. London: British Association for Emergency Medicine, 1992. Horton R. The realpolitik of a new National Health Service for the UK. Lancet 1998; 351: 76-77. Fatovich DM, Jacobs IG. Emergency department telephone advice: a survey of Australian Emergency Departments. Emerg Medi 1998; 10: 117-121. Best Practice in NSW Health 1994 Sydney. 49-52. Crouch R, Patel A, Williams S, Dale J. An analysis of telephone calls to an inner city accident and emergency department. J R Soc Med 1996; 89: 324-328. Egleston CV, Kelly HC, Cope AR. Use of a telephone advice line in an accident and emergency department. BMJ 1994; 308: 31. Verdile VP, Paris PM, Stewart RD, Verdile LA. Emergency department telephone advice. Ann Emerg Med 1989; 18: 278-282. Levy JC, Rosekrans J, Lamb GA, Friedman M, et al. Development and field testing of protocols for the management of pediatric telephone calls: protocols for pediatric telephone calls. Pediatrics 1979; 64: 558-563. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics 1979; 64: 553-557. Aitken ME, Carey MJ, Kool B. Telephone advice about an infant given by after-hours clinics and emergency departments. N Z Med J 1995; 108: 315-317. Dunn JM. Warning: giving telephone advice is hazardous to your professional health. Nursing 1985; 8: 40-41. (Received 7 Oct 1997, accepted 26 Mar 1998)

Authors' details

School of Public Health, Department of Epidemiology & Biostatistics, Curtin University.
Ian G Jacobs, PhD, RN, Senior Lecturer.

Reprints will not be available from the authors.
Correspondence: Dr D M Fatovich, Department of Emergency Medicine, Swan District Hospital, Eveline Road, Middle Swan, WA 6056.
E-mail: daniel.fatovichAThealth.wa.gov.au