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Use of a Telephone Nursing Line in a Pediatric Neurology Clinic: One Approach to the Shortage of Subspecialists

Megan A. Letourneau^*, Daune L. MacGregor, MD^*, Paul T. Dick, MDCM, E. J. McCabe, RN^*, Anita J. Allen, RN^*, Valerie W. Chan, RN^*, Lynn J. MacMillan, RN^* and Meredith R. Golomb, MD

^* Division of Neurology
Pediatric Outcomes Research Team and Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana

	ABSTRACT

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Objective. There are not enough pediatric neurologists to meet the many needs of pediatric neurology patients. The Hospital for Sick Children has responded by expanding the nursing role in the pediatric neurology outpatient clinic. The objective of this study was to examine the use of a telephone nursing line in this hospital-based pediatric neurology clinic.

Methods. A cross-sectional study was performed on all telephone call records collected during a 2-week study period. Each initial incoming call concerning a patient was counted as an index call. Associations between clinic type or diagnosis and length of telephone calls were assessed using the ² test.

Results. A total of 208 index calls were received, generating a total of 597 incoming and outgoing calls. The most common clinic types were Epilepsy clinic (35.6%) and General Neurology clinic (32.7%), and the most common patient diagnoses were epilepsy (63.5%) and developmental delay (45.2%). Most patients were between the ages of 1 and <7 years (33.9%) and 12 and <18 years (32.8%) and male (55.2%). Most calls were made by mothers (57.2%) to ask about medical administrative issues (28.4%) and/or symptoms (27.9%). Physicians were notified for 47.1% of calls; nurses were twice as likely to notify physicians for calls concerning new symptoms (relative risk: 2.1; 95% confidence interval: 1.6–2.7). Most calls required between 1 and 5 minutes (49.0%). Long telephone calls (>10 minutes) were strongly associated with a diagnosis of epilepsy.

Conclusions. There is a high demand for the neurology nursing line in our clinic. Most telephone calls and most long telephone calls concerned patients with epilepsy. Nurses managed more than half of all telephone calls without physician assistance. Use of a nursing line can aid in the provision of care to complicated subspecialty patients. Additional strategies are needed to optimize delivery of care to high-need medical populations.

Key Words: telemedicine • telephone triage • telephone advice • telephone • nursing • management • neurology • pediatric neurology

Abbreviations: HSC, Hospital for Sick Children • CI, confidence interval • ED, emergency department

During the past decade, there has been a decrease in the number of pediatric postgraduate trainees in fellowship programs in the United States and Canada.^1–3 A recently published survey of pediatric residents’ career intentions revealed that 56% planned to enter general pediatrics, whereas only 21% planned to pursue subspecialty fellowships.¹ Pediatric neurology has been particularly affected; in 1998, the number of full-time equivalent child neurologists in the United States was estimated to be 20% below demand. This shortfall is expected to remain unchanged through 2020.⁴

The shortage of pediatric neurologists and the case management needs of complex pediatric patients call for a multidisciplinary approach to providing continuing medical care in a pediatric neurology clinic. One approach is to make more use of allied health care workers for tasks such as managing telephone calls. Telephone calls demand a substantial amount of physician and nurse time. Nurses with advanced training are capable of addressing call issues such as prescription refills, dose adjustments, test results, and worsening symptoms.

The Neurology Outpatient clinic at the Hospital for Sick Children (HSC) in Toronto employs 4 clinic nurses whose role includes answering telephone calls from parents, physicians, pharmacies, and allied health care workers. Three of the 4 neurology clinic nurses are certified Canadian Neuroscience Nurses. The nursing line in the clinic is used to address parent needs, triage medical issues, and redirect administrative calls to the booking office. The nurses report that this telephone line is heavily used. The time spent on the telephone has been reported to vary considerably, from a few seconds to >15 minutes. The goals of this study were to examine the volume of calls directed through the nursing line, to describe who calls and for which reasons, and to determine whether there is a subpopulation of high-need callers who make longer calls.

	METHODS

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Setting
The HSC, Division of Neurology, routinely sees patients in the General Neurology clinic as well as 11 subclinics and 2 combination clinics: Consult, Epilepsy, Headache, Ketogenic Diet, Movement Disorder, Multiple Sclerosis, Neurodevelopmental, Neuroinvestigational, Neurometabolic, Neuromuscular, Stroke, General Neuro/ Neuromuscular, and General Neuro/Demyelinating. There are 4 clinic nurses and 13 staff neurologists. Each nurse is associated with specific subclinics and acts as an HSC contact person for clinic patients’ families. During the January 1 to December 31, 2001, fiscal year, the outpatient pediatric neurology clinic handled 5566 patient visits.

In January 2002, the nursing line answering service was reformatted to triage calls to the voicemail of individual nurses. Nurses pick up messages throughout the day and return calls between clinic appointments. They document all calls using telephone documentation sheets.

Study Design
All consecutive telephone call records during a 2-week study period were collected prospectively. The sample population was composed of all calls received and resulting calls made between May 13 and 26, 2002, by the neurology clinic nurses over the neurology nursing line.

Data Collection
Demographic data collected from telephone documentation sheets included the following variables: clinic type, diagnoses, neurology medications, age, and sex; caller and relationship to patient; reasons for call; follow-up action; and approximate call length. Nurses documented the approximate amount of time that they spent on the call: <1 minute, 1 to 5 minutes, 5 to 10 minutes, or >10 minutes. Data regarding the entire neurology clinic population, including the number of clinic visits per subclinic for the fiscal year January 1 to December 31, 2001, were obtained from the Neurology Clinic Central Booking Office.

Data Analysis
Each initial incoming call concerning a patient with 1 or more new issues for that patient was defined as an index call, and the total number of index calls was tabulated. The number of subsequent outgoing response calls and repeat incoming telephone calls associated with each index call were also tabulated and included in the calculation of the total number of calls. A call was defined as any recorded attempt at contacting a person by telephone, including all incoming and outgoing voicemail messages, and unsuccessful attempts by nurses to reach a busy line. Repeat incoming calls were generated when parents called back to clarify a point in a previous conversation or to respond to a nurse’s voicemail message. Proportions and 95% confidence intervals (CIs) describing the group of index calls were calculated. Clinic types, diagnoses, and reasons for call were assessed for associations with a response of notifying a physician or a length of >10 minutes using the ² statistic and relative risks. For all analyses, P = .05 was considered statistically significant. The SAS software package⁵ was used to perform all analyses. This study was approved on May 8, 2002, by the HSC, Research Ethics Board, Toronto, Ontario.

	RESULTS

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Number of Calls Received
During the 2-week study period, 208 index calls were received, generating a total of 597 documented incoming and outgoing telephone calls. Two incoming calls concerned 2 patients each. Each of these calls was counted as 2 separate calls so that patient data could be collected. A median of 21 index calls were received per day (25th percentile: 10.5; 75th percentile: 23.5).

For 50.0% (95% CI: 43.0–57.0) of index calls, 1 call out was generated in response (25th percentile: 1.00; 75th percentile: 2.00). Twenty-five percent (95% CI: 19.3–31.5) of index calls generated 2 calls out in response; only 12.5% (95% CI: 8.3–17.8) did not require a return call; and the remaining 12.5% (95% CI: 8.3–17.8) generated >2 outgoing calls in response.

Description of Calls Received
Subjects of Telephone Calls
Telephone calls came in most frequently regarding patients seen in the Epilepsy clinic (35.6%), General Neurology clinic (32.7%), Combined General Neurology/Neuromuscular clinic (10.6%), and Neurodevelopmental clinic (10.1%; Table 1). A total of 19.5% (95% CI: 13.7–25.4) of telephone patients attended >1 clinic. The total number of telephone calls generated by each of the 3 largest clinics during the 2-week study period was larger than the average number of clinic visits to each of these clinics in a 2-week period during the 2001 fiscal year (Fig 1).

View larger version (44K): [in this window] [in a new window]   Fig 1. The total number of incoming and outgoing calls from patients in each of the 3 largest clinics during the 2-week study period and the average number of visits to each of those clinics during a 2-week period in the previous fiscal year.

Seventy-five percent (75.3%) of patients were on at least 1 medication for their neurologic problem. Data on number of medications were missing for 18 index calls.

Calls occurred most frequently for patients who were 1 to <7 years of age (33.9%) and 12 to <18 years of age (32.8%). Calls were made more frequently regarding boys (55.2%). Data regarding age were not available for 16 index calls; data concerning sex were missing for 14 index calls.

Who Called
Most telephone calls were made by patients’ mothers (57.2%; 95% CI: 50.2–64.0), with "other" (13.6%; 95% CI: 9.1–18.9) and physicians (10.6%; 95% CI: 6.7–15.6) being the next most common callers. Fewer than 10% (8.6%; 95% CI: 5.2–13.3) of telephone calls were made by fathers.

Reasons for Calls
A total of 23.9% (95% CI: 17.9–30.8) of callers had >1 reason for their call. The most common reasons given for calls were administrative issues, such as completing government forms to get medication coverage and rescheduling appointments earlier or later than planned based on clinical status (28.4%; 95% CI: 22.3–35.0); new, changing, or worsening symptoms (27.9%; 95% CI: 21.9–34.5); "other" (27.4%; 95% CI: 21.5–34.0); and test results (17.8%; 95% CI: 12.8–23.7). "Other" included requests for blood work schedules, questions regarding when to start medications, and messages of thanks to doctors or nurses.

Responses to Telephone Calls
Nurses notified physicians of the telephone call for 47.1% (95% CI: 40.2–54.1) of index calls (Table 2). Physicians decided case by case whether to take over all additional follow-up and varied widely in their approach to follow-up. Nurses thought that additional follow-up was unnecessary for 33.7% (95% CI: 27.3–40.5) of index calls. Other nurse responses to telephone calls included giving the caller reassurance (17.8%; 95% CI: 12.8–23.7) and calling a pharmacy (6.7%; 95% CI: 3.7–11.0). Percentages are not cumulative, as many calls required >1 follow-up action.

High-Need Callers: Long Telephone Calls
Long telephone calls, defined as calls >10 minutes in length, were strongly associated with a diagnosis of epilepsy (² = 7.519, P = .006) and being seen in the General Neurology clinic (² = 4.705, P = .03). No other diagnosis or clinic type was significantly associated with long telephone calls. Calls concerning complicated epilepsy patients, which we defined as epilepsy patients on 2 or more neurologic medications, were more likely to be long telephone calls (relative risk: 1.9; 95% CI: 1.1–3.2).

	DISCUSSION

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The field of pediatric neurology is facing a shortage common to many pediatric subspecialties because of the significant decrease in the number of pediatricians entering pediatric neurology fellowships.² Pediatric neurology clinics are finding it difficult to meet the demand. Members of the Child Neurology Society reported in a recent survey that the mean wait for a new patient clinic visit in the United States is 49 days, and 12% of patients must wait 3 or more months to be seen.⁶ Increasing the nursing role in the provision of patient- and family-oriented care is one way to distribute workload and extend the amount of care that physicians can provide.

Responding to telephone calls is time-consuming and expensive but important for ensuring the continuity of patient care. Today, telephone calls are often used to manage medical issues that required clinic or emergency department (ED) visits in the past.^7,8 Pediatricians may spend >20% of their weekly time giving telephone advice.^9–11 Garaizar et al¹² reported that over the course of 1 year, a Spanish pediatric neurology clinic received between 150 and 200 calls per month, approximately equivalent to two thirds of their clinic visits and requiring approximately 10% of the clinic staff’s work time.

A trained nurse is capable of providing effective telephone triage. Nursing telephone advice services are inexpensive and convenient for the caller.^8,13 A province-wide survey of a Quebec telenursing service revealed that 80% of respondents saved on average 5 hours of time and 3 hours of child care costs, 60% avoided transportation costs, and almost 25% avoided losing time on the job.¹⁴ Previous studies have suggested that telephone triage saves physician time¹⁵ and may lower the number of inappropriate ED visits.¹⁶ The Province of Ontario offers a telehealth triage service staffed by registered nurses, which was operational during the time this study was conducted. This service, however, does not provide specialty-specific advice or have any direct link to physician services following children.¹⁷ The American Academy of Neurology and American Association of Neuroscience Nurses have recognized the value of nurse telephone triage and have worked together to produce a manual of nursing telephone protocols designed to address common concerns in adult neurology patients.¹⁸ We are unaware of any similar manuals for nurses who work with pediatric neurology patients. Approximately one quarter of all calls concern new or worsening symptoms, but our service usually does not deal with emergent problems because most calls initially go to an answering machine. Although our nurses sometimes respond to nursing line calls by directly advising patients to go to the ED, this did not happen during our 2-week study period, and we do not know whether our service prevented inappropriate ED visits.

The liability associated with telephone triage is a significant concern.^7,8,19,20 It can be very difficult to obtain a clear history and assess the severity of the illness without the benefit of a physical examination.¹⁹ Possible reasons for lawsuit include improper or delayed treatment, breach of confidentiality,^8,20 practicing outside the boundaries of a license,^7,8 and failing to make the correct diagnosis or arrangements for appropriate follow-up.^7,20 These risks can be minimized with appropriate training.^7,8,15,20,21 Some telenursing programs use protocols to address the most common problems and ensure accuracy and consistency between calls.^8,15,22 At our clinic, nurses have neurology training and extensive clinical experience and know the patients and their families. Callers are always directed to go to an ED in an emergent situation or if they are still concerned after speaking with the nurse.

The high volume of calls received by our neurology clinic nurses during this study demonstrates the high patient demand for telephone medical care at our hospital. We counted all outgoing calls in our total count regardless of whether a parent was reached, because all calls contributed to the nurses’ workload. We estimated that the neurology clinic nurses spent a cumulative total of 15 hours per week in direct time on the telephone. Although we are not aware of any workload study examining nurses’ indirect telephone time (eg, time spent locating patient charts or communicating with a physician regarding a parent’s request), we estimate the total time (ie, direct plus indirect) devoted to telephone calls to be at least double the time spent on telephone calls. This is the equivalent of close to 1 full-time clinic nursing position.

The most frequent subjects of calls and those generating the most incoming and outgoing calls overall, were Epilepsy clinic patients, closely followed by General Neurology clinic patients. During the January 1 to December 31, 2001, fiscal year, the Neurology clinic saw 1453 patients in the Epilepsy clinic and 955 patients in the General Neurology clinic, corresponding to approximately 56 and 37 patients, respectively, in a 2-week period. Although data collected in this study over a 2-week period cannot be compared directly with available clinic statistics, the data as presented in Fig 1 suggest that for each of the 3 largest clinics, the total number of calls is much greater than the average total number of visits in a typical 2-week period. This supports our view that telephone medicine is an important part of ongoing patient care.

We found that mothers were the most frequent callers and that the most frequent reasons for telephone calls were medical administrative issues (28.4%), symptoms (27.9%), "other" (27.4%), and test results (17.8%). Garaizar et al¹² noted similar proportions of telephone calls from mothers asking about symptoms. The high number of administrative calls in our study reflects the increasing amount of paperwork required in patient care; many of the administrative calls concerned forms needed to document that children qualified for government medical assistance programs. However, nonmedical administrative personnel may have been able to handle some of those calls.

We noted that parents of patients with epilepsy, particularly Epilepsy clinic patients on 2 or more neurologic medications, were more likely to make long telephone calls. These results suggest that epilepsy management should be an intrinsic part of neurology clinic nurse training to manage and appropriately triage telephone calls. Other subspecialties may find it helpful to identify high-need subpopulations among their patients as they plan for training allied health personnel to respond to telephone calls.

Our study does suggest that nurses can manage many telephone issues and thus save physician time. In our study, nurses managed just more than half of index calls, notifying the physician in 47.1% of calls. They triaged the more urgent issues, such as new symptoms, to physicians, while managing routine questions and medical administrative issues.

There are limitations in our study. The number of calls managed by our nursing line and the amount of time spent handling them may be underrepresented. Any calls that came in before May 13 were not included, even if follow-up calls were being made during the study period. Our study was conducted during late spring; the number of calls may be higher during winter months, when children are prone to infections that may exacerbate neurologic symptoms. The recorded length of each call does not include time spent looking through charts, speaking with physicians and allied health professionals, faxing, mailing, and e-mailing. We did not have follow-up studies to assess patient satisfaction or appropriateness of nursing advice; this is an area for future study. During the 10 months after our study, we were not aware of any serious complications resulting from nursing telephone advice.

Pediatric neurologists and other subspecialists can benefit from working with allied health professionals in providing telephone care. Analyzing the patient population served and identifying high-need subpopulations will aid in planning appropriate training. By working together, we can better address the complicated medical and personal needs of our patients and their families.

	ACKNOWLEDGMENTS

 
We thank Dr Jose Biller for assistance with medical translation and Melanie Lameront and Elizabeth Uleryk, MLS, for technical assistance.

	FOOTNOTES

 
Received for publication Dec 16, 2002; Accepted Mar 26, 2003.

Address correspondence to Meredith R. Golomb, MD, Riley Hospital for Children, Pediatric Neurology, Rm 1757, 702 Barnhill Dr, Indianapolis, IN 46202. E-mail: mgolomb{at}iupui.edu

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