Journal of the New Zealand Medical Association, 11-July-2003, Vol 116 No 1177
A telephone advice line does not decrease the number of presentations to Christchurch Emergency Department, but does decrease the number of phone callers seeking advice
David Graber, Michael Ardagh, Paul O’Donovan and Ian St George
In May 2000, a 24-hour, 7-day-a-week telephone advice line (Healthline) began service for Canterbury and three other pilot regions of New Zealand. The service was supported by the Ministry of Health, which contracted private providers to deliver it from a Wellington-based call centre. The cost to run the pilot for the four regions for two years was $7.5 million, which included set-up, capital, and operating expenses. Healthline uses decision-support software in the form of binary-chain logic algorithms. The algorithms are designed to help the registered nurses taking the calls to rule out important conditions (however rare), and stop at the condition that cannot be excluded; they thus set the level and timing of the intervention. There are over 570 symptom-based algorithms, and over 1200 self-care instructions. The algorithms are able to triage patients safely to appropriate care, while at the same time providing comprehensive, automated call documentation and reporting for analysis, risk management and quality improvement.1
Christchurch Hospital is the tertiary referral centre for the Canterbury region, serving a population of approximately 412 000. Its emergency department (ED) is the only one in the region; it was thus well placed to study the effect of a new telephone advice service on emergency care.
Although there have been reports of locally-based telephone advice services,2 and of the overall results of regional systems,3 the effect of independent telephone advice lines on emergency medicine has not been specifically assessed in Australasia in the peer-reviewed medical literature. Telephone advice services range from limited arrangements covering individual general medical practices to large-scale systems with integrated appointment capabilities, such as the Northern California Kaiser Permanente system in the USA with 50 000 calls a day (personal communication, Moore D, Permanente Medical Group, April 2001). The proliferation of telephone advice in the USA is mostly driven by managed care systems, which will not share their experiences in a non-proprietary manner. The peer-reviewed literature focuses on the safety of such systems4 or the appropriateness of ED referrals made through them,5 but there is little information on the overall effect of independent advice systems on emergency care. An analysis of the United Kingdom National Health Service’s ‘NHS Direct’ demonstrated a small and insignificant effect on the use of emergency departments and ambulance services.6
The aims of this study were to determine if Healthline significantly changed the ED census at Christchurch Hospital, if the acuity of the referrals through Healthline was similar to those of the general ED population, and if Healthline affected the number of telephone advice calls answered by ED nursing staff.
This was a prospective review of clinical records.
Using encounter logs generated by the information system in the Wellington call centre, Healthline collected full clinical records on all callers, including their answer to the question, ‘What would you have done if Healthline had not been available?’ The answer was recorded as the ‘intent’ of the caller. Healthline gathered data on age and sex, and the clinical rationale for referral of patients to the ED. The anonymous nature of this information precluded direct cross-checking of individual cases, but served as an independent body of data with which to compare hospital-derived statistics.
These data on individual patients who had contacted Healthline were faxed in standardized format to the ED before the patients’ arrival, to allow staff to anticipate patient needs. The fax took the place of the usual general practitioner (GP) referral letter. In addition, logs of the faxed notes were transmitted weekly from Healthline to the ED during the study period.
We examined a six-month study period from August 2000 to January 2001 and compared data with monthly ED census data from the same six-month periods over the preceding five years (when Healthline was not running), using a computerised patient registration and tracking system (Patient Management System, © Sun Microsystems). We extracted triage codes and admission/discharge destinations. The ED censuses before and after Healthline were evaluated by Poisson regression using the PROC GENMOD procedure in SAS/STAT® Version 8 (SAS Institute Inc., Cary, North Carolina, USA).
Referral acuity was assessed by examination of the proportions of patients admitted and their triage categories according to the Australasian Triage Scale. This scale categorises patients according to their urgency for emergency care, from category 1 (most urgent) to category 5 (least urgent).7 The triage breakdown and the proportion admitted for those referred by Healthline were compared with all other ED patients.
The Christchurch ED nurses provide telephone medical advice. Call logs were examined and volumes tabulated from January 2000 to January 2001 – ie, for six months before and six months after the start of the Healthline service. When Healthline started, callers to the ED were presented with a phone menu, which encouraged those seeking medical advice to select a number that would transfer them to Healthline. Those seeking advice related to a recent ED visit were encouraged to make a selection that would allow direct contact with ED staff. Callers who did not wish to be transferred to Healthline had the option of speaking with a member of the departmental nursing staff. Direct transfer to the Plunket line or the National Poisons Centre was also available. This phone menu system was in place about six weeks after the launch of Healthline.
During the study period Healthline received 10 238 calls from the Canterbury region, of which 7097 callers were seeking symptom triage. Of those calls, 5% (345 patients) were referred to the Christchurch ED, either by private transport or by referral to the ambulance service. Healthline data on intent show that of the 451 (6%) callers who would have called an ambulance or gone direct to the ED, only 75 (17%) were advised to do so after triage; on the other hand, of the 6646 (94%) callers who would not have called an ambulance or gone direct to ED, 270 (4%) were advised to do so. These data suggest that approximately 106 fewer patients (1.5% of 7097), would have gone to the ED as a direct consequence of ringing Healthline, if all patients had followed Healthline’s advice. Figure 1 summarises the caller intent and call outcome details.
Figure 1. Healthline caller intent and outcomes, 1 August 2000 to 31 January 2001
1. Total number of calls from Canterbury during study period: 10 238
2. Total number of callers referred to Christchurch ED (by any means): 345
3. Total number of calls from Canterbury wanting symptom triage: 7097
(excludes those wanting general health information or non-clinical information)
5. Difference in ED attendance if all patients followed Healthline advice:
451 intending to go to ED - 345 actually referred = 106
Healthline transmitted details by fax of patients due to arrive by private transport in 97% (230/237) of referrals. Healthline was not able to arrange a notification system when a patient was referred to the ambulance for transport to the ED. Thus, the ED received advance notification and patient information details in 67% of all Healthline referrals (230/345) prior to arrival. Of the patients arriving by private transport, records of triage categorisation were available in 76% (179).
Sixty per cent of those referred were female, and 74% of calls were made outside the hours of 8am to 5pm; 31% of the callers triaged to the ED were referred to an ambulance for transport.
The symptoms triggering calls included chest pain (21%), paediatric (0–12 years) problems (16%), abdominal problems (15%), adult trauma (13%), and range of less-frequent problems including respiratory symptoms, syncope, palpitations, gynaecological symptoms, and psychiatric issues.
Figure 2 compares the six-month study period total ED census with the same six-month period over the preceding five years.
Figure 2. Monthly emergency department (ED) census 1 August 2000 to 31 January 2001 compared with same period for previous five years
During the study period there was a small but significant (p = 0.04) increase in ED attendance of 1.1% when compared with the periods of the preceding five years.
The mean admission rate for 1995–1999 was 40%; for 2000, it was 47% (p <0.01). During the 1995–1999 periods, a mean of 8.6% of all patients were allocated triage category 1 or 2; during the year 2000 study period, 9.5% were allocated category 1 or 2 (p = 0.48).
Table 1 compares the triage categories and admission rates of Healthline-referred patients against the entire population of ED patients during the study period.
Table 1. Acuity markers in Healthline-referred vs all emergency department (ED) patients
Figure 3 shows the effect of Healthline on calls direct to the ED requesting advice.
Figure 3. Emergency department patient advice call volume
We were most interested to know if the introduction of the Healthline system would noticeably decrease ED utilisation, or, as some feared, result in a large increase in patients who otherwise would not have presented to the ED. In one authors’ experience, the initiation of a telephone advice service may be accompanied by increases in inappropriate referrals to EDs as a result of poorly refined algorithms: in a USA-based programme, direct participation of an emergency-medicine doctor in a telephone advice system was necessary to limit a large number of inappropriate visits.
The volume of calls to Healthline from Canterbury was between 50 and 60 a day, but the number of patients sent to the ED as a result of the calls averaged only two a day. Although the patient intent data from Healthline suggests up to 106 fewer ED presentations may have resulted from patients accessing the service, this represents an average of less than one patient a day. As the usual ED census is 180 a day, and the daily variation can be considerable, Healthline is unlikely to make a measurable difference to ED presentations.
The call rate from the service population was lower than to some other advice systems3,8 but similar to the rate of calls made to NHS Direct in the UK.6 Concerns about increased or decreased numbers of presentations to the ED appear to be groundless. However, it is possible that as the public becomes more familiar with the service a ‘learning effect’ may transpire and change this conclusion.9
The triage category comparisons suggest the acuity of Healthline referrals is similar to those of the general ED population, although the difference in admission rates may suggest lower acuity in the Healthline group. The lower percentages of patients presenting in the first two triage categories following Healthline referrals are not unexpected, as many of those more ill patients will contact the ambulance service directly, rather than seek telephone advice.
The acuity of Healthline referrals is likely to be higher than reported here. Healthline was unable to provide any notification for ambulance patients, so the data for many of these patients (which are likely to have had greater acuity) were missed from analysis. Admission rates are likely to be underestimated in the Healthline group for the same reason.
In summary, although these figures suggest Healthline referrals were generally of lower acuity than those for other ED patients, there is no proof that this is the case. We would expect the inclusion of ambulance-derived data to raise the acuity of referrals over that observed.
This population was demographically similar to those reported in previous studies with respect to female preponderance and percentage of calls taken after hours, but there were, inexplicably, fewer children presenting.3,4,6
Members of the nursing staff appreciated the deferral of the majority of advice calls to Healthline, saving them time and avoiding documentation issues. In fact, this was the most important impact of the Healthline service: one nurse was freed from answering the telephone and was able to work elsewhere in the ED.
In conclusion, this study demonstrates little effect of an independent telephone advice line on overall ED census, but lower workload for those ED nursing staff usually charged with answering advice calls.
Author information: David J Graber, Consultant; Michael W Ardagh, Professor of Emergency Medicine; Paul O’Donovan, Clinical Charge Nurse, Emergency Department, Christchurch Hospital, Christchurch; Ian St George, Medical Director, Healthline, Wellington
Acknowledgements: No funding was received for this study. Dr Ian St George is employed by Healthline. We thank Dr Angela Pitchford, Clinical Director, Christchurch Emergency Department for invaluable advice and suggestions, and Dug Yeo Han of the Department of Public Health and General Practice, Christchurch School of Medicine, University of Otago for statistical assistance. In addition, we are indebted to Jamie Richardson, Site Director of Healthline for generously supplying us with all requested data. Finally, this project was completed only due to the cooperation and participation of the entire emergency department doctor, nurse and reception staff.
Correspondence: Dr David J Graber, Emergency Medicine, Kaiser Foundation Hospital, 2025 Morse Avenue, Sacramento, California 95825, USA. Fax: +1 916 967 6979; email: DnJGraber@aol.com
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