Damian McNamara

November 06, 2013

ORLANDO, Florida — About 1 in 3 children and adolescents referred to the emergency department by an after-hours nurse telephone triage service were considered nonessential referrals, a new study has found.

"Although after-hours nurse telephone triage services improve the lifestyle of the outpatient pediatrician — and have been shown to standardize care — our research suggests that a large number of nonurgent patients are referred to the emergency department when perhaps they could be managed in the outpatient setting," said Kaynan Doctor, MD, from the Children's National Medical Center in Washington, DC.

In the after-hours telephone triage service, nurses follow computerized algorithms to advise callers on a course of action. The service is similar to after-hours triage services used by many pediatrician practices nationwide, Dr. Doctor explained.

To determine if the triage system was over-referring children after hours to the emergency department and "inundating an already overburdened service," his team analyzed records at Penn State Milton S. Hershey Medical Center in Pennsylvania, where Dr. Doctor worked at the time of the study.

Dr. Doctor presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

The study involved patients younger than 18 years referred exclusively by triage nurses at the call center, independent of any physician influence.

A large number of nonurgent patients are referred to the emergency department when perhaps they could be managed in the outpatient setting.

A physician panel reviewed electronic medical records for admission data and emergency department care to classify referrals to the emergency department as either essential or nonessential. Referrals were considered essential if patients warranted immediate evaluation or required essential interventions, such as serum lab tests, imaging, complex procedures, intravenous medications, consultation, or admission.

Of the 220 referrals to the Children's National Medical Center over a 1-year period, 33% were classified as nonessential and 67% were classified as essential. Patients in the nonessential group were significantly younger than those in the essential group (P < .05 ), had lower triage scores (P = .026), and had shorter stays in the emergency department (P < .0001).

The researchers evaluated the individual algorithms used by the call center. "Five algorithms used by the call center that we critically analyzed resulted in the most nonurgent referrals," Dr. Doctor reported.

"We suggest a revision of these algorithms by a panel of expert physicians to get them up to speed with the most up-to-date opinions and evidence-based medicine," he said.

Table. Common Reasons for a Nonessential Referral

Complaint Percent
Fever in a child 3 months or older 12.3
Vomiting without diarrhea 8.2
Head trauma 8.2
Headache 6.8
Sore throat 5.5


"Overall, this is an interesting study," said Henry Ortega, MD, from the Children's Hospitals and Clinics of Minnesota in Minneapolis, who was asked by Medscape Medical News to comment. "It shows what many of us who work in pediatric emergency departments seem to experience daily."

"Although this study appears to be representative of a single institution, it probably reflects what is happening at many institutions that use triage call centers to determine how sick a child really is with only information obtained from a caregiver over the telephone," said Dr. Ortega, whose institution employs a similar nurse telephone triage system. "It would be very interesting to repeat this study at multiple centers."

Dr. Doctor acknowledged that this was a retrospective study, which makes it more "difficult to gauge the appropriateness of such referrals." Going forward, he said, he would like to conduct a prospective study to compare different institutions, call centers, and feedback from emergency medicine physicians to verify these findings.

Dr. Doctor and Dr. Ortega have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2013 National Conference and Exhibition. Presented October 25, 2013.


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