Objectives
- To highlight 3 goals of phone advice
- To review techniques for gathering medical information over the phone
- To identify important components of phone advice documentation
- To review options for management and disposition
More information can be found in this introductory PDF
Goals of Phone Advice
1) Answer simple medical questions: An estimated 17% of phone advice calls involve requests for medical information (Carbajal et al, 1996). For these calls, the goal is to provide medical knowledge and may be an opportunity for educations.
Example- “My newborn is sneezing, is this normal?”
2) Advise disposition:One of the most important tasks of phone advice is determining the patient’s severity of illness. Diagnosing the problem is often not necessary. The main goal of your phone conversation is often to advise a disposition for the patient based on TRIAGING.
3) Recommending treatment is sometimes a component of medical phone advice. This might be advising home symptomatic care, calling in medical prescriptions, or recommending treatment while patient is en route to seek medical attention.
Examples- Advising dosing of diphenhydramine for a rash or recommending rectal diazepam for a patient with known seizure disorder while waiting for an ambulance.
Importance of Phone Advice
1) Phone advice helps decrease unnecessary use of ED. 2/3 of calls from parents who initially intended to go to the emergency room were deemed NOT urgent by the call center.
2) Phone advice helps decrease the chance that urgent medical evaluation is delayed. 15% of calls from parents who initially intended on staying home were deemed URGENT by call center.
3) Phone advice may be cost-effective. Average estimated savings per call is $50.
4) Caregivers like it! Statistically significant differences were found on overall satisfaction with the advice and importance of being involved in decision-making.
Techniques for Obtaining History over the Phone
1) Get a call back number in case you are disconnected.
2) Start with the most acute symptom and then work down in severity to the least acute.
Example- Parent calls about a child’s fever, but mentions the child is having difficulty breathing. The questions should then focus on the child’s difficulty breathing rather than the length of the fever in order to determine if emergency intervention is necessary.
3) Use yes/no or either/or questions to avoid “grey areas" and focus on pertinent history.
4) Avoid medical jargon and be specific about your questions.
Example- A parent’s understanding of “wheezing” may mean stridor or congestion. “Is there a high pitched nose when your child breathes out?” may be more clear.
5) Review active problem list and PCP. Confirm with medical record (if possible).
6) Social history may affect disposition. Acronym R-A-T-E:
Reliability: Language, education, and understanding
Example-Is the interpreter conveying all information? Can the caller repeat the plan?
Abuse: Physical, emotional, sexual, and substance abuse
Example-Is the caller or patient in danger? Is the caller intoxicated?
Travel Distance & Access: Transportation and access for follow up
Example-How far away is the closest emergency room? Is it safe to drive (weather)?
Emotional: Distress, anxiety, fear, complete hysteria
Example-Is the caller too emotional to follow through with the plan?
Physical Exam over the Phone
1)Help the caller be your “eyes”: Ask specific questions about exam findings.
Example-Instead of “is your child dehydrated” ask “ does the child’s mouth look dry”.
2) Some systems are easier than others: Mental status (sleepy, playful); Respiratory (cyanosis, flaring, rate); Skin (size, location, description). Callers may have drastically different abilities in describing their child’s condition. Know your caller’s comfort level!
Management Options
1) Where to triage:Recommended management dependent on the severity of the symptoms and the patient’s condition. Remember that the patient’s condition may change over time.
Example-911 (If possible, have parent call 911 from another phone so that you can stay on the line and provide support until EMS comes), closest ED, urgent Care, follow up with PCP the next day, phone follow-up, home care management
2) Prescriptions: Simple medications such as Amoxicillin may be called in. Refills for medications such as albuterol also may be called in, but follow up is advised.
3) Call back reasons:Signs for parents to be aware of and return to medical attention if present.
Documentation Tips
1) Name of caller, relationship to patient, patient identification:Check spelling and DOB.
2) Exact dosage of a medication or dosing interval should be documented if:
(a) The patient has a specific medication question
(b) You suspect an adverse drug reaction (dose-related side effect or overdose)
(c) You are calling in a prescription for a medication
3) Allergies:Document if patient has rash or you are recommending medication (even OTC)
4) Clear description of the recommended disposition and call back reasons.
Example-Patient is in respiratory distress. Recommendations: Caller contacted 911 using cell phone. Albuterol advised while waiting for ambulance. EMS arrived at 2:15 AM.
Resources
1) Barton Schmitt Phone Triage Protocols: on-the-spot guides with step-by-step protocols, according to AAP guidelines. Most commonly used resource in pediatric call centers.
2) MD4Kids: an iphone application that uses AAP guidelines similar to above, but more portable!
Take Home Points
1) Determining severity and triaging are often more important than making the diagnosis
2) Be specific and descriptive when gathering information over the phone & R-A-T-E the caller
3) Management depends on symptom severity & patient’s condition, which may change over time
4) Document your recommendations
5) Err on the side of caution – it is better to over-refer to urgent care/ED, than under-refer.
6) Never underestimate GUT FEELING on either end of the telephone
References
1. Bunik M, Glazner JE, Chandramouli V, Emsermann C. Pediatric telephone call centers: how do they affect health care use and costs.Peds,119(2):305-13, 2007.
2. Carbajal R, Barthez P, Viala J, Manceron V, ,Simon N.Evaluation of pediatric advise asked by telephone in emergency units.Arch Ped. 3(10): 959-63, 1996.
3. KidsDoc Symptom Checker. American Academy of Pediatrics. http://www.healthychildren.org/english/tips-tools/symptom-checker/Pages/default.aspx, 2010.
4. Oberlander TF, Pless IB, Dougherty GE. Advice seeking and appropriate use of a pediatric emergency department. Am J Dis Child, 147(8): 863-7, 1993.
5. Schmitt, BD. Pediatric Telephone Protocols: Office Version, 12thEdition. American Academy of Pediatrics, 2008.
6. Schmitt BD, Thompson DA. Triage Documentation: Setting a Best Practice. http://www.answerstat.com/articles/5/42.html, 2005.
7. Thompson T, Stanford K, Dick R, Graham J. Triage Assessment in Pediatric Emergency Departments: A National Survey. Ped Em Care, 26(8):544-548, 2010.
8. Wood PR. Pediatric resident training in telephonea management: surveying programs in the United States. Pediatrics, 77:822-825, 1986.
Phone Advice Written by Jessica Myers, MD
National Pediatric Nighttime Curriculum Lucile Packard Children’s Hospital, Stanford