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Optimizing the Use of Telephone Nursing Advice for Upper Respiratory Infection Symptoms

Rosalind Harper, PhD, RN; Tanya Temkin, MPH; and Reena Bhargava, MD
Telephone nursing advice for home care offers an effective and clinically appropriate way to manage upper respiratory infection symptoms for adult members of a large integrated health plan.
To describe efforts to optimize telephone self-care advice for upper respiratory infection (URI) symptoms by registered nurses in Kaiser Permanente Northern California’s Appointment and Advice Call Center, and to assess the sufficiency of this advice.

Study Design: Retrospective observational study.

Methods: The study sample included 279,625 calls from adults 18 years and older that resulted in self-care advice for URI symptoms in 2009. Utilizing electronic medical records of these calls and follow-ups, we determined the rate of return calls within 7 days and the clinical outcomes associated with these. Advice for self-care at home was considered sufficient if no return calls received within 7 days of the original call were associated with the need for a “higher” level of care, such as an appointment. Results: Self-care advice was sufficient for 88% of index advice calls, with either no follow-up calls within 7 days associated with a higher level of care, or follow-up calls only for additional advice or nonmedical information.

Conclusions: Telephone advice for self-care by registered nurses can effectively manage URI symptoms for most otherwise healthy adults.

Am J Manag Care. 2015;21(4):264-270
Take-Away Points
  • Multiple work flow adjustment and quality assurance strategies, supported by electronic medical records, help ensure that registered nurse (RN) management of upper respiratory infection (URI) symptoms for otherwise healthy adults is safe and feasible.
  • Service demand is expected to increase with implementation of the Affordable Care Act. Diverting some lower-risk concerns such as URIs to RN-managed self-care advice can reduce appointment demand and improve clinic access for more acutely ill patients.
  • Future research can assess the sufficiency of self-care nursing advice for additional lower-risk symptoms.
Telephone consultation services include the processes by which calls are received, assessed, and managed through advice for self-care at home or referrals to other clinically appropriate services.1 These services are designed to help patients obtain optimal access—that is, “the right care at the right service in the right place”2,3—and reduce demand on clinic-based services.4,5

Safe telephone consultation requires that patients be directed to the level of service required to treat the seriousness of their conditions.6 Studies of the appropriateness of nurse telephone consultation in adult general medical populations have predominantly focused on the comparison of nurse and physician advice rates, audits and reviews of nurse triage decisions by expert panels, and timing of follow-up visits in relatively small samples.7-9 Most studies have addressed the quality of triage decisions in general, without specifically assessing the adequacy of self-care advice.

In a large-scale study, Munro surveyed 2748 calls to NHS Direct, the nurse-led telephone hotline serving England, Wales, and Scotland, and used an expert panel to assess the appropriateness of nursing triage in terms of whether the contacts were necessary and sufficient for the presenting symptoms. Healthcare contacts were deemed necessary if the patient could not have been treated at a “lower” level of service; they were considered sufficient if there were no follow-up contacts associated with a “higher” level of service within 48 hours following the initial contact. Self-care advice was considered to be the lowest level of service. Nurses gave self-care advice in about 26% of the cases, and about 80% of the care recommendations provided by nurses were judged by the patients and experts to be appropriate.10 A later study by Snooks of NHS Direct Wales evaluated the appropriateness of advice and contacts made after calls using the same methodology and found similar results.11

We opted to study self-care advice for upper respiratory infection (URI) symptoms for 3 main reasons. First, URI symptoms are generally low-risk concerns amenable to treatment with self-care advice in lieu of a clinic appointment—coughs and colds are generally self-limiting, lasting from 3 to 10 days.12 Second, URI is a high-volume concern all year long. The National Ambulatory Medical Care Survey has estimated that acute respiratory infections other than pharyngitis are consistently among the 5 leading diagnostic groups for ambulatory care visits.13 Likewise, at Kaiser Permanente Northern California’s Appointment and Advice Call Center (AACC), URI symptoms are among the 5 most frequent types of calls received monthly. Finally, since URI symptoms are highly contagious, there are strong incentives to minimize appointments, thereby reducing the spread of infection at clinics and in the community.

Utilizing Munro’s concept of sufficiency, our study considered nursing advice for self-care management of URI symptoms to be sufficient if callers receiving such advice did not call back within 7 days for URI symptoms and receive a higher-level call outcome, such as a clinic appointment.

The study was reviewed and approved by the Kaiser Permanente Northern California Institutional Review Board.

Practice Setting
The AACC at Kaiser Permanente Northern California (KPNC) was introduced into a large integrated healthcare system in 1997, and now serves more than 3.2 million patients. The AACC is open 24 hours a day, 7 days a week, and receives over 1 million calls monthly.

This call center uses 3 types of representatives. During daytime and evening hours, calls are initially answered by unlicensed teleservice representatives (TSRs) who follow structured scripts to give information, schedule appointments, or send messages to medical providers at 1 of over 50 clinics. Callers with symptoms that require further assessment are transferred to registered nurses (RNs) who use more than 350 computer-based, symptom-specific decision support protocols as guides to manage callers within their primary care specialties of medicine, pediatrics, or obstetrics and gynecology. Between 12 am and 6 am, RNs receive calls directly. Board-certified emergency medicine physicians are also available to serve as call center consultants for registered nurses.

A single call may involve multiple scripts or protocols related to the caller’s symptoms and may involve multiple referrals to different levels of healthcare service. In decreasing order of clinical urgency, these referral outcomes are:

• Emergency department (ED) referral by RNs via ambulance or other means of transport, after consultation with a physician.

• Booking by TSRs or RNs for a clinic appointment, or sending the clinic a message asking the clinic to contact the caller to schedule an appointment. A telephone consultation with a call center physician can also be booked under this outcome. Bookings and appointment request messages utilize symptom-specific “booking guidelines” and script and protocol identifiers indicating the reason for the appointment.

• Sending a message from TSR or RN to the caller’s physician for non-appointment reasons such as providing feedback about treatment plans, requests for changes in medications, or referrals to other services.

• Advice by RNs only for self-care of the caller’s URI symptoms.

• Other outcomes, such as providing non-clinical information (eg, information about facility hours of operation or directions) by TSRs only.

For selected symptoms, RNs may employ telephone treatment protocols (TTPs). Nurses screen callers through inclusion and exclusion criteria, and call center physicians prescribe medication electronically if eligibility requirements are met. For URI symptoms, physicians select cough suppressant medications and antibiotics only for patients matching strict criteria for bacterial sinusitis. During flu season, an antiviral medication may be ordered for patients who call within 48 hours of the onset of symptoms and who meet the strict criteria indicating influenza. Patients can pick up the medications at any pharmacy within 4 hours and start their treatment promptly.

Nurses managing URI calls also have computer access to electronic medical records incorporating demographic information, prior diagnoses, call history, visit history, and prescribed medications. This information allows nurses to identify patients with chronic conditions, review the frequency and history of prior calls, and determine if telephone treatment was recently prescribed for URI symptoms. Before the winter flu season, nurses are also given extensive education about URI symptom management by physicians and nurse educators, as well as through online training. The AACC issues reports that rank-order nurses based on their call outcomes in order to identify those with the highest advice rates for URI symptoms, and those with the highest rates are encouraged to manage URI calls in a separate “flu queue” when URI call volumes begin to rise. The AACC also provides taped and Web-based information about home cold and flu management for patients, along with information about where to obtain flu shots.

The scripts and protocols used by AACC TSRs and RNs are based on evidence-based research and the results of feedback from medical care providers, as well as practice guidelines from the CDC, public health authorities, state laws, and internal quality reviews. The AACC digitally records all calls, and the recordings are the basis for random retrospective monitoring of the RN triage process. Physician representatives from the chiefs of Medicine, Obstetrics/Gynecology, Pediatrics, and Emergency Services departments at KPNC oversee the development of the scripts and protocols, with support by RNs who are content experts in medicine, pediatrics, or obstetrics/gynecology. The content revision process is supported by detailed reports on monthly frequencies for all scripts and protocols and their associated rates of call outcomes. These reports enable the content oversight committees to examine the impact of the calls on AACC performance and facility operations, and to make revisions to improve quality.

Revisions are set up on a revolving schedule according to body systems and frequency of use, but in response to urgent and rapidly emerging needs in the community, these tools can be revised and deployed within a matter of hours. For example, during the 2009 H1N1 influenza pandemic, the CDC issued new guidelines for the management of H1N1 influenza,14 and KPNC clinics rapidly modified their isolation procedures, necessitating frequent updates in protocol triage instructions and specific appointment booking instructions for each medical clinic.

The scripts and protocols specific to URI address cough, cold, sinusitis, and influenza symptoms. Per protocol instructions during the study period, callers reporting URI symptoms and who had certain chronic conditions (eg, history of asthma, chronic obstructive pulmonary disease, or emphysema) but reported only sinus symptoms were triaged under protocols specific to those chronic conditions. Callers reporting URI symptoms who receive self-care advice get a robust set of recommendations for managing their symptoms, information about the safe use of medications, suggestions about lifestyle and preventive measures, course of illness expectations, and instructions to call back if symptoms worsen or new symptoms develop.

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