Caller Satisfaction With After-Hours Telephone Advice: Nurse Advice Service Versus On-Call Pediatricians
Sanford M. Melzer, MD, FAAPChildren’s Hospital and Regional Medical Center
Department of Pediatrics, University of Washington School of Medicine
Seattle, WA 98108-0371, USA
To the Editor.—
In their recent article, Lee et al1 report that callers seeking after-hours triage and advice were less satisfied with medical advice provided by a nurse service compared with an on-call pediatrician. In this study, a large national for-profit service bureau that offers many different types of telephone services, including information, referral management, and hospital marketing calls, provided the triage services. The authors devote considerable time in the article addressing the study’s limitations, including the question of whether the study findings can be generalized to other practice settings. They speculate that satisfaction may have been greater if a children’s hospital call center had been utilized.
The results reported by Lee et al (55% satisfaction rate with nurse triage) stand in contrast to other studies that have reported patient satisfaction rates of 94% to 98%2–4 for hospital-based pediatric nurse triage services. Two factors might account for differences in satisfaction between parents using children’s hospital programs and a national service bureau—the level of pediatric nursing expertise and the protocols used. In many offices and hospital call centers, managers place a premium on a high level of pediatric expertise in recruiting telephone nurses, and train nurses to move through triage and advice algorithms in an efficient and timely way.
The study by Lee et al does not indicate the level of pediatric experience among the nurses or protocols used. The nurse call time of 14.5 minutes they report is nearly 30% longer than the 11.3 minute time reported in a large national study of children’s hospital call centers5 and substantially longer than the 5-minute average time spent by nurses for clinical calls in a study of pediatric practices in Colorado.6 This suggests that triage nurses in the present study either had lengthy protocols to administer or were less familiar with pediatric triage than pediatric nurses in office or hospital settings. In the Lee et al study, shorter calls were associated with higher satisfaction, and this is not surprising. The long duration of the calls, either related to nurse experience or protocols used, may have raised questions about the nurse’s expertise or credibility in the minds of the callers and contributed to the patient dissatisfaction and low compliance rate reported.
There is a growing body of evidence supporting the notion that children’s hospital-based telephone triage and advice centers, using standardized pediatric protocols and pediatric trained nurses, offer high-quality care and result in a high level of patient satisfaction and compliance with recommendations.2,7,8 Lee et al correctly note that many children’s hospital call centers "limit their services to the immediate surrounding area for business reasons." Previous studies have documented the poor financial performance of these programs,4 which arise in part because third-party payors do not reimburse either physicians or nonphysicians for telephone care. This is an issue of great concern to pediatricians. In a more favorable reimbursement environment that adequately recognized the clinical value and cost savings of telephone care, children’s hospitals could expand triage and advice services. Under these circumstances, clinicians and large managed care organizations could look to children’s hospitals that specialize in pediatric telephone triage and advice as an alternative to national service bureaus, thereby raising the general level of patient satisfaction while providing a valuable service to pediatricians and the community.
REFERENCES
- Lee TJ, Guzy J, Johnson D, Woo H, Baraff LJ. Caller satisfaction with after-hours telephone advice: nurse advice service versus on-call pediatricians.
Pediatrics.2002; 110
:865
–872
[Abstract/Free Full Text] - Kempe A, Luberti AA, Hertz AR, et al. Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance. Pediatrics.2001; 108(6) . Available at: http://www.pediatrics.org/cgi/content/full/108/6/e111
- 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
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[Abstract/Free Full Text] - Pert JC, Firth TW, Katz H. A ten year experience with pediatric after hours telecommunications. Curr Opin Pediatr.1996; 8 :181 –187[Medline]
- Melzer SM, Poole SR. Computerized after hours call centers at children’s hospitals: operating characteristics, financial performance, and perceived value.
Arch Pediatr Adolesc Med.1999; 153
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[Abstract/Free Full Text] - Poole SR, Glade G. Cost-efficient telephone care during pediatric office hours. Pediatr Ann.2001; 30 :256 –267[Web of Science][Medline]
- Kempe A, Dempsey C, Whitefield J, Bothner J, MacKenzie T, Spole S. Appropriateness of urgent referrals by nurses at a hospital based pediatric call center.
Arch Pediatr Adoles Med.2000; 154
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[Abstract/Free Full Text] - Barber JW, King WD, Monroe KW, Nichols MH. Evaluation of emergency department referrals by telephone triage.
Pediatrics.2000; 105
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–821
[Abstract/Free Full Text]
Thomas J. Lee, MHS, MD
UCLA Emergency Medicine Center
David Geffen School of Medicine at UCLA
Los Angeles, CA 90024, USA
David Johnson, PhD
McKesson Health Solutions
Broomfield, CO 80021, USA
Larry J. Baraff, MD
UCLA Emergency Medicine Center and Mattel Children’s Hospital
Los Angeles, CA 90024, USA
In Reply.—
Several factors discussed in our article might account for the lower satisfaction with telephone triage nurses observed in our study compared with prior studies. However, we doubt that the difference in satisfaction can be accounted for by either a lack of pediatric nursing expertise or the protocols used. Although the commercial triage service we studied is not based at a children’s hospital and the telephone triage nurses are not necessarily pediatric nurses, one third of all telephone calls for medical advice are for children, approximately 3500 pediatric calls per year per nurse, making it doubtful that the nurses lack experience with pediatric calls.
High satisfaction has even been reported for telephone triage using non-nurses.1 Part of the difference in our satisfaction scores may be accounted for by methodology. In the most recent study cited by Melzer, Kempe et al2 reported overall satisfaction (very/somewhat) as 96.8% using the highest 2 ratings on a 4-point Likert scale. We used a 5-point Likert scale ("poor," "fair," "good," "very good," "excellent") and reported satisfaction in the nurse group as "very good" or "excellent" as 58%. Had we included "good," the overall satisfaction in both the nurse (73.1%) and physician (86.6%) groups would have been higher.
Although we have not compared the protocols directly, the service we studied uses triage algorithms that are chief complaint driven similar to other services, and have been field-tested and modified over a time period of 25 years. The multiple studies reporting high satisfaction have used different protocols, reducing the possibility that satisfaction was related to the nature of the protocols. We believe that the other factors discussed in our article might have played a greater role, especially 1) the unusually high parental education of our subjects and 2) their expectation to speak with a pediatrician, which had been their exclusive experience until the time of the study. Kempe et al2 reported that educational level was a significant predictor of parental preference to speak with a physician rather than a nurse.
We demonstrated that length of call may have affected caller satisfaction, and agree that the length of call in the nurse group might account for some of the difference in satisfaction. However, we do not think this is a result of lack of triage nurse experience, but rather the detailed nature of data-gathering required by the computer algorithms used by this nurse advice service and the recording of this information in the database. We found no difference in triage decisions between the physician and nurse groups and believe this suggests that the quality of the nurse triage advice was excellent (data submitted for publication).
REFERENCES
- Katz HP, Pozen J, Mushlin AI. Quality assessment of a telephone care system utilizing non-physician personnel.
Am J Public Health.1978; 68
:31
–38
[Abstract/Free Full Text] - Kempe A, Luberti AA, Hertz AR, et al. Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance. Pediatrics.2001; 108(6) . Available at: http://www.pediatrics.org/cgi/content/full/108/6/e111
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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