title: Evaluation of an after-hours call center: are pediatric patients appropriately referred to the emergency department?
abstract: BACKGROUND
  There is concern that after-hours nurse telephone triage systems are overwhelming the emergency department (ED) with nonemergent pediatric referrals.
  
  
  OBJECTIVE
  This study aimed to critically review a nonpediatric hospital-based call center with the aim of identifying the algorithms responsible for the majority of nonessential referrals.
  
  
  METHODS
  This is a retrospective observational study performed at a tertiary medical care facility over 1 year. Telephone triage forms of children and adolescents younger than 18 years, exclusively referred by triage nurses using the Barton Schmitt protocols, were reviewed, and their ED course was evaluated by consulting the electronic medical record. "Essential" referrals to the ED were classified as presentations warranting immediate evaluation or referrals requiring "essential interventions" such as serum laboratory tests, imaging, complex procedures, intravenous medications, subspecialty consultation, or admission.
  
  
  RESULTS
  A total of 220 patients were included in this study. Of these, 73 (33%) were classified as nonessential, whereas 147 (67%) were classified as essential. Nonessential patients were significantly younger compared with essential referrals (P < 0.05). They also had lower triage scores (P = 0.026) and shorter ED stays (P < 0.0001). The algorithms for "fever-3 months or older" (12.3%), "vomiting without diarrhea" (8.2%), "trauma-head" (8.2%), "headache" (6.8%), and "sore throat" (5.5%) were determined most likely to result in a nonessential referral.
  
  
  CONCLUSIONS
  Our study identifies that a third of unnecessary pediatric visits to the ED occurred as a result of the nurse triage telephone system in question. We recommend review of the algorithms stated to reduce strain on local ED resources.
authors.affiliation: From the *Division of Emergency Medicine, Children's National Medical Center, Washington, DC; †Department of Emergency Medicine, Temple University Hospital, Philadelphia; and ‡Department of Emergency Medicine and Pediatrics, Penn State M.S. Hershey Medical Center, Hershey, PA.
authors.forename: Kaynan
authors.initials: K
authors.lastname: Doctor
authors.forename: Kelly
authors.initials: K
authors.lastname: Correa
authors.forename: Robert P
authors.initials: RP
authors.lastname: Olympia
mesh_terms: D039602:After-Hours Care; D002675:Child, Preschool; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014218:Triage