Teaching residents to communicate: The use of a telephone triage system in an academic ambulatory clinic

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Abstract

Objective

This study evaluated the use of a telephone triage system in an academic primary care clinic and its impact on communication, patient management and satisfaction.

Methods

A “telephone clinic” was created using a triage nurse to answer patients’ calls to an academic primary care clinic, staffed by house staff physicians. Chart reviews were conducted of all medical records of patients who called and were referred to the telephone clinic during a six month period. A total of 1135 patient calls were monitored. Using a random selection process, 366 patient calls were studied and 42% of these patients were called back two weeks after the initial call and were interviewed.

Results

Of the 336 calls, 68% of the calls were serious enough to be referred to a house staff physician. Symptom complaints accounted for 64% of the telephone calls; 4% of patients were sent to the emergency room or admitted to the hospital directly based on the information from the call. Telephone calls enhanced patients’ access to specialty care consultative services and 14% of patients who called received a new medication prescription. Patients’ satisfaction with the communication and the overall care provided by the “telephone clinic” was highly rated.

Conclusion

The telephone contact initiated by the patients resulted in expedited access for patients whose symptoms were serious enough to require immediate referral to the emergency room or direct hospital admission.

Practice implications

In a primary care practice, the telephone can be a major source of communication for practitioners, office staff and patients. The creation of a “telephone clinic” which utilizes nurses and house staff physicians trained and dedicated to telephone communication directly with patients resulted in more efficient management and greater satisfaction for patients.

Introduction

In a primary care practice, the telephone can consume up to 30% of the average practice day and can be a major source of communication for practitioners, office staff and patients [1]. Telephone calls range from concerned patients who simply need a medication refill to more serious symptom complaints [2]. Practically, a physician cannot spend quality and personal time on the phone with every patient that calls. Our study was developed to evaluate the use of a telephone triage system in an Academic Primary care clinic staffed with one hundred thirty-five house staff physicians.

Balas analyzed all published clinical trials for a thirty-year period (1966–1996) evaluating the use of distance medicine technology, including telephone communication and its impact on health care outcomes in clinical practice [3]. Of eighty clinical trials studied, only four studies involved telephone access to patients. They were 24 h, usually emergency service interventions which uniformly produced positive outcomes by reducing hospital use and decreasing anxiety about medical problems [4], [5]. Another review found similar positive effects on health care use and patient satisfaction [6]. Although studies have analyzed numerous forms of telephone use (reminders, screening, follow-ups, computerized counseling), none have studied the use OR convenience of a telephone triage system as part of a primary care practice or its impact in an academic clinic with internal medicine house staff physicians.

Our study was developed to evaluate the use of a telephone triage system in an academic primary care clinic staffed by one hundred thirty-five internal medicine house staff physicians. The house staff physicians each have a weekly continuity clinic with an assigned panel of patients, which they follow over their three years of internal medicine residency training. The objectives of the study were:

  • 1.

    To analyze the workload of the telephone calls to a primary care clinic;

  • 2.

    To determined the purpose of each call and identify patient characteristics and common problems prompting telephone calls;

  • 3.

    To develop and implement a triage system using house staff resident physicians to manage calls to the primary care clinic;

  • 4.

    To assess the effectiveness of the phone interaction, including patterns of care that resulted and patient satisfaction;

  • 5.

    To track the specific medical outcomes of the calls such as medications ordered, impact on clinic and emergency room visits, and hospitalizations.

Section snippets

Methods

We created a practice that designated a triage nurse to answer patients’ calls to the academic primary care clinic. The clinic was staffed by internal medicine house staff physicians who were part of the Jackson Memorial Public Health trust, University of Miami Training program. All physician and nursing staff were trained on telephone communication and triage skills. The nurses utilized a hospital protocol for triage based on level of illness acuity. A medical house staff physician was

Results

The average age of patients who called into the Academic Medical clinic was 62 ± 8 years and there were no significant differences compared to those patients who were ultimately referred to the “telephone clinic” for physician call back. Both groups of patients had attended the academic primary care clinic on average 7 ± 2 years.

Disposition by the triage nurse of the 336 phone calls is listed in Table 1; 63% of the calls were deemed serious enough to be referred to the house staff physicians. Of

Discussion

Access through telephone communication provides a significant extension of primary care clinic services for patients. House staff physicians can be trained in telephone communication protocols and work with nurses in an academic primary care clinic to enhance services and management their patients. Although telephone contact is used to reduce the use of physician clinic time, most symptom complaints and medication issues resulted in clinic appointments. However, telephone screening provided

Conflict of interest

No commercial or grant funding was used to support the conduct of this research study. There are no conflicts of interest to report in the conduct of the study.

Acknowledgements

We wish to thank Janeen Andrews, Starline Hodge and the Nursing Service in the Academic Ambulatory clinic at the Miami VAMC for their assistance and support in accomplishing this project.

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