After-hours telephone triage affects patient safety.

OBJECTIVE: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment. STUDY
DESIGN: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage. POPULATION: Primary care physicians and their telephone answering services. OUTCOME MEASURES (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls.
RESULTS: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%-77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician.
CONCLUSIONS: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.