How safe is triage by an after-hours telephone call center?
OBJECTIVE
Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center.


METHODS
The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations.


RESULTS
Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral.


CONCLUSIONS
Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.
Kempe
Allison
A
Department of Pediatrics, Children's Hospital, 1056 E 19th Ave, B032, Denver, Colorado 80218, USA. kempe.allison@tchden.org
Bunik
Maya
M
Ellis
Jennifer
J
Magid
David
D
Hegarty
Teresa
T
Dickinson
L Miriam
LM
Steiner
John F
JF
D000293:Adolescent; D039602:After-Hours Care / Q000706:statistics & numerical data; D001071:Appointments and Schedules; D002648:Child; D002675:Child, Preschool; D003120:Colorado; D003953:Diagnosis-Related Groups; D004630:Emergencies / Q000451:nursing; D005260:Female; D006279:Health Maintenance Organizations / Q000458:organization & administration / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009726:Nurses; D009819:Office Visits / Q000706:statistics & numerical data; D010290:Parents / Q000523:psychology; D010349:Patient Compliance / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012449:Safety; D013689:Telephone; D014218:Triage / Q000706:statistics & numerical data