Telephonic Nurse Triage and Emergency Room Utilization Griselda Chapa, MPH, MS 1 , Thomas Kotsos 1 , Antonio Linares, MD. 2 , Ken Hunter, DPA 1 , Kejian Niu, MS 3 , Jeff Kriner 4 HMC, 1 Chicago, IL , 2 WellPoint, Walnut Creek, CA, 3 Richmond, VA, and 4 Atlanta, GA, USA.
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Griselda Chapa, MPH, MS1, Thomas Kotsos1, Antonio Linares, MD.2 , Ken Hunter, DPA1, Kejian Niu, MS3, Jeff Kriner4HMC, 1Chicago, IL , 2WellPoint, Walnut Creek, CA, 3Richmond, VA, and 4Atlanta, GA, USA.
Annual Research Meeting 2009 ARM | June 28-30 | Chicago, IL
Figure 1: Baseline NurseLine Emergency Room Visit Results
Previous research on telephonic nurse triage systems has reported difficulties in evaluating outcomes. Some research has documented that callers may not follow nurse advice and, therefore, any evaluation that does not examine claims overestimates savings. Cost avoidance methodologies have been employed; however, these have struggled with determining appropriateness of emergency room utilization.
We conducted a baseline study of our telephonic nurse triage system, NurseLine, by taking a national random sample ( N = 316) of cases where the caller intended to go to the emergency room before speaking with a nurse. We found that NurseLine callers were less likely to use the emergency room for nonemergent conditions. Nonemergent conditions were defined using severity adjusted procedure codes.
78% of the study sample sought medical services the day of the call and of this 17% had an office visit. Very few callers went to the emergency room for nonemergent conditions.
The findings of the baseline study prompted us to conduct a population study (N = 2,779,110) that would apply the knowledge gained on emergency room utilization to test the hypothesis that callers to NurseLine are less likely to use the emergency room when their conditions do not require emergency care. Because emergency room costs include facility and ancillary costs, e.g., lab and pharmacy, appropriate emergency room utilization can control costs. Also, directing people into appropriate care has implications for improved quality of care.
The progression of modern physician practice in recent decades has led to a model of care that finds physicians with less time to treat and advise their patients. One way that health care companies have tried to close this gap is to implement telephonic nurse triage systems. Theses are also known as nurse lines (NL) to provide guidance to callers regarding medical care. These are services provided by specially trained nurses to callers reporting a variety of medical complaints of varying severity. Nurses use decision support software to assist them in determining what advice to give the caller.
Telephonic programs are not a new methodology used to enhance health care advice to patients. The first recorded instance of assistance via telephone was recorded in 1879.1 By 1997, this had evolved to more than 500 nurse triage and advice systems serving 35 million Americans.2 Moreover, telephone advice nursing is the fastest growing nursing specialty.3 This growth has been exacerbated by a combination of concerns involving controlling unnecessary costs while providing quality services and maintaining customer satisfaction.4 The use of telephonic methods has been the subject of over 500 articles.5
Results from the population study reiterate the findings from the baseline study – callers are less likely to use the emergency room for nonemergent conditions but more likely to use the emergency room when their condition is coded as truly emergent.
The population study demonstrated that the intervention group was less likely to use the emergency room when it was not necessary( p<.001, CI 1.48,1.56 . Moreover, when the condition was truly emergent, the intervention group was more likely to use the emergency room (p<.001, CI 1.55,1.64 ).
An analysis of diagnosis codes demonstrated that conditions related to the highest CPT codes were diagnoses such as acute appendicitis and heart attacks. These conditions require timely attention to mitigate the possibility of long term adverse effects. In the examples presented here, an appendicitis not attended in a timely fashion could lead to septicemia. Similarly, a heart attack could lead to congestive heart failure.
Our results indicate that a telephonic NL program encourages appropriate emergency room utilization thereby reducing unnecessary costs and improving quality of services.
Our findings are particularly salient given the recently reported shortages of primary health care physicians.7 Lack of primary care has been linked to higher ER utilization. According to the most recently available national CDC data, an increase in ER visits has coincided with decreasing numbers of emergency care providers. This has resulted in overcrowding in hospital ER’s nationwide.8 Moreover, the same study classified only half of all ER visits as requiring immediate, emergent or urgent care.
Figure 2: Population Study Emergency Room Utilization
Our findings suggest that privately insured individuals prefer not to use the ER when their condition can be treated in a non-emergency setting. Given the costs associated with an ER visit, which involve professional, facility, and ancillary, e.g., pharmacy and supply, fees, we believe nurse triage systems do produce cost savings. Additionally, by channeling callers to appropriate services, they do not have to be in crowded emergency rooms where a low severity condition is likely to have a long wait time for treatment.
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1Lancet. Practice by Telephone. Lancet 1879;2:2819.
2 Cariello FP. Computerized Telephone Nurse Triage: An Evaluation of Service Quality and Cost. J Ambul Care Manage 2003;26:124-137.
3 Valanis B, Tanner C, Moscato SR, et al. A Model for Examining Predictors of Outcomes of Telephone Nursing Advice. J Nurs Adm. 2003;33(2):91-95.
4 O’Connell JM, Johnson, DA, Stallmeyer J, et al. A Satisfaction and Return-on-Investment Study of a Nurse Triage Service. AJMC 2001;(7):159-169.
5 Omery A. Advice Nursing Practice: On the Quality of the Evidence. J Nurs Adm 2003;33:353-360.
6 Shapiro SE, Shigeko I, Tanner CA, et al. Telephone Advice Nursing Services in a US Health Maintenance Organization. J Telemed Telecare 2004;10:50-54.
Our research involved a two stage process where we first selected a random sample of NL callers who reported they intended to go to the emergency room prior to speaking with a NL nurse. We discovered that following a NL call, 17% had office visits. Moreover, we found that callers appeared to use the emergency room appropriately.
We then examined a population and divided into two cohorts where the intervention group had access to the NL service.
Findings from the baseline study that prompted the population study demonstrated that callers using emergency room services were more likely to use the emergency room when their condition was classified as truly emergent. Figure 1 displays the distribution of visits by severity code for the baseline study.
Acknowledgements: We would like to thank Jason Crock and Chang Su for their help with data issues, Susan McKenney and Suzanne Sullivan for program data and Britt Parrack for editorial support.