Roberts, James R. MD
Author Credentials and Financial Disclosure: James R. Roberts, MD, is the Chairman of the Department of Emergency Medicine and the Director of the Division of Toxicology at Mercy Health Systems, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia. Dr. Roberts has disclosed that he has no significant relationships with or financial interests in any commercial companies that pertain to this educational activity. Wolters Kluwer Health has identified and resolved all faculty conflicts of interest regarding this educational activity.
Learning Objectives: After reading this article, the physician should be able to:
1. Discuss the current recommendations in giving medical advice to patients who call the ED.
2. Explain the potential problems in giving medical advice to patients who call the ED.
3. Describe solutions for the problems in giving medical advice to patients who call the ED.
Release Date: September 2005
Telephone calls from patients or potential patients to emergency departments seeking immediate and free medical advice from emergency physicians and emergency nurses are omnipresent. They include the anxious and distraught mother of a 1-year-old with a fever, patients looking for work notes, individuals with bona fide medical problems, and those investigating waiting times and looking for specific physicians on duty.
Some calls are a minor nuisance, but others involve important issues, and improper handling of the interaction can lead to untoward outcomes. The most worrisome calls are related to potential serious medical problems, such as meningitis, stroke, or myocardial ischemia. These issues are difficult enough to deal with in the ED, and trying to solve them over the phone is a foolish endeavor. Everyone is looking for a quick fix, but it's just not in the cards. The naïve patient is reassured by the lack of concern from the medical staff about a sign or symptom, and the medical staff is too busy and too distant to give the situation much credence.
Pediatricians and general practitioners deal with phone advice on a regular basis. Some become very good at it, but EDs universally do a lousy job. Some busy office practices have nurses who reliably dispense medical advice over the phone, including information about fever, diarrhea, vomiting, and a plethora of other issues and also report lab or x-ray results. Although phone advice appears to work well for the majority of patients in a pediatric or general office practice, calls to the ED are generally more problematic, and can be downright disastrous.
Unlike a private practice, the individual or concerned friend or relative calling the ED is usually totally unknown to the medical staff. There is usually no specifically trained individual available in the ED designated to field such calls. The overworked and overcrowded conditions in most EDs do not lend themselves to a thorough investigation of even the most minor complaint. An ED phone interaction is an opportunity to provide a real service to paying patients and to promote good public relations, but this goal is rarely achieved in real life.
Most physicians and nurses are simply annoyed at the thought of dispensing gratuitous medical advice over the phone to a stranger. The usual response from the clerk or nurse is a simple, “We don't give medical advice over the phone.” This is usually preceded by the annoying question: “Did you call your doctor?” Likely the answer is always no, but it's still asked routinely. Of course, most ED-bound patients don't have this specific luxury or relationship and certainly not a readily available private physician.
This month's column explores the intricacies of medical advice given over the telephone from the ED. As a general rule, it is not standard of care, nor a particularly prudent activity, to attempt to treat a sick patient over the phone, especially via a third party such as a parent or spouse. The last thing the patient needs is incorrect advice, or an attitude that conveys the concept that the ED has no interest in him at all.
“Call your doctor” is an approach that rarely solves anything for the patient or the ED. “Call an ambulance or 9–1-1” or “come on in” are probably the best medical opinions emanating from an ED. Usually phone advice does not foster or negate the need for a subsequent ED visit, but trying to dissuade yet another ED patient by a hurried attempt at being helpful is a quagmire that you do not want to enter.
Providing Telephone Advice from the Emergency Department Proctor J, et al Ann Emerg Med 2002;40:217
This is a recent position statement (termed a policy resource education paper) from the American College of Emergency Physicians exploring the ramifications of telephone medical advice given in the ED. The overview begins by stating that the general public considers the ED a potential source of reliable medical information, even though the ED may not have a similar view of itself. A broad range of inquiries make its way to the ED phone lines.
Seekers of free advice are looking for anything from basic first aid information to detailed advice and real answers about general or specific medical conditions. Because of the pressures on the overall U.S. health care environment, detailed medical advice from the ED is becoming the exception rather than the rule. Despite the public's optimistic view of the responsibilities or social mandate of hospitals, most medical personnel consider telephone advice an additional unrealistic demand on the ED staff.
It has been well established that even an onsite ED triage evaluation is often a poor predictor of patient acuity or the need for immediate hospitalization. Even with a face-to-face encounter, the urgency of the patient presentation or the need for ultimate hospital admission is not well predicted. The sensitivity of nurse, physician, or computer triage in predicting eventual hospital admission of actual patients who come to the ED ranges from 40 percent to 70 percent. Interestingly, computer triage seems to do better than physicians or nurses. Under EMTALA, telephone triage has not yet been deemed equivalent to “coming to the hospital,” so phone contact does not fall under EMTALA jurisdiction — yet.
In the interpretation of EMTALA, triage alone without appropriate subsequent medical screening cannot be the sole criterion for determining the need for further ED care. Specifically, providing a level of care that would be used in triage, such as merely logging an initial chief complaint, has not met the definition of medical screening. The pitfalls of triage are only exaggerated by reliance on an attempt at telephone screening. Although telephone advice has not yet met the criteria of “coming to the hospital” under EMTALA, it is nonetheless a patient encounter of some sort.
Telephone advice clearly does not allow one to assess the patient visually or to verify the accuracy of the medical information conveyed by a third party. If a face-to-face initial triage encounter in the hospital is problematic in determining the seriousness or stability of a medical condition, telephone contact must be viewed as an even more inferior assessment tool.
Although there may be a role for ED telephone triage with the use of trained personnel and specific algorithms, this paper suggests that EDs should restrict telephone advice to three basic categories. The first is a call for information on what someone perceives as a bona fide medical emergency. Such patients should be immediately advised to access the 9–1-1 system.
In the second scenario, the patient is looking for basic first aid advice, such as cleaning an abrasion or using ice or heat for a soft tissue injury. Basic advice of this nature is usually acceptable. With regard to basic first aid, this paper suggests that the ED should establish policies and procedures regarding the provision of standard medical advice for nonemergency conditions. It is suggested that this first aid should be documented and monitored. Under no circumstances should the medical advice exceed the most basis level.
Finally, telephone advice is often sought by patients who have been treated recently in the ED. With regard to patients who call the ED following a prior emergency physician encounter, it is suggested that as much demographic information be obtained as possible, and specifics of the ED visit should be determined. Under such circumstances it would be reasonable to discuss the concerns, document the advice that was provided, and under ideal circumstances what the caller agreed to do. Obviously all these activities would require continuing medical education of the ED staff and documentation safeguards.
The editors of this article state that the provision of telephone advice for medical toxicology appears to be the poster child for rational phone intervention. Because of the focused nature of poison or toxin exposure and the omnipresence of poison information centers, the system appears to work relatively well.
With regard to telephone advice within the managed care industry, an entity that has turned to the telephone as a means of triage and a way to allocate medical resources, the issues become even more clouded. Fortunately, emergency physicians are not at the end of such phone calls. Attempting to provide medical care over the phone that is based on some organization's view of the appropriate use of resources, with a veiled attempt to limit “unnecessary ED visits,” can be very problematic. Trying to steer a patient to a certain facility also is fraught with potential problems. A medico-legal analysis has demonstrated the shortcomings of this system, and the authors offer two examples from case law.
The first was a 6-month-old infant who was directed to an in-network hospital facility instead of a closer out-of-network hospital, resulting in the infant's death. A similar outcome occurred when a man was instructed to use an antacid for indigestion, and the patient actually had a myocardial infraction.
As a general rule, the American College of Emergency Physicians and the authors of this paper recommend that the emergency department maintain policies and procedures with regard to telephone advice. Although “quality” and “appropriate” medical information dispensed over the telephone is supported, procedures to safeguard that mandate are very problematic. With the exception of the caveats above, it is advised that EDs not attempt medical assessment or medical management by telephone.
Comment: The suggestions given in this paper are easier said than done, and currently there does not appear to be any standard of care with regard to this issue. Hospitals are caught in the bind of trying to be patient-friendly, informative, and helpful and yet not contribute to the problem. Even beginning the discussion of chest pain, fever, or headache over the phone has a placebo effect, so don't get caught in that trap. Certainly I would advise putting pressure on a bleeding artery, washing out an eye with a chemical splash, or cooling a scalded hand, but that advice is only given with a follow-up “call 9–1-1.”
I have a very stringent and minimalist policy about phone advice: Don't do it! Essentially, I believe that you get what you pay for, and free medical advice, especially over the phone, is usually worthless. The major downside is that your best intentions may actually be harmful. I would avoid trying to handle any medical problem over the phone at all costs. I have enough trouble with indigestion vs. myocardial ischemia in the ED. Trying to figure it out blindly and from a distance with a description from a patient's wife is lunacy.
Like it or not, the general public expects that a call to an ED will glean useful medical advice. Nothing could be further from the truth. Even a motivated ED staff performs poorly. Answering the phone in the ED and talking to a potential patient is a slippery slope. While the ED does not want to appear uncaring, cold, or antagonistic, trying to unravel the vagaries of any medical condition on the phone is futile. I think failure is much more likely than success. Although some fantasize that a written log should be kept of telephone interactions, this has not been the standard, and is likely impossible in most busy ED milieus.
If there is a problem with your advice, there is no way that a brief note in a log book will help you defend a bad outcome. Providing a proper chart for an on-site ED patient is difficult enough. Any sort of reasonable documentation would include a complete medical history with detailed advice being documented. This is simply humanly impossible, probably counterproductive, and it is yet another source of potential litigation because of the inherent shortcomings and complexity of the scenario.
Parenthetically, I note that every time I call a doctor's office, the first caveat on the automatic phone message is this: “If this is a medical emergency, hang up and call 9–1-1 or go to the ED.” It looks like most offices have it right; it's about time the ED does the same.
Nonetheless, there is often someone in the ED willing to chat with an anxious caller. Telephone advice from the clerk is often “motherly” or “fatherly” advice rather than true medical advice. I hear it all the time: Clerks or nurses attempt to relate the approach they would use with their child with a fever or how they would treat their in-laws or parents in a similar situation. I maintain that no clerk or secretary should ever give telephone advice. Most telephone advice emanates from a busy ED nurse, usually the one who has the time or inclination to pick up the phone when the overhead page squawks for the fourth time.
I believe nurses give generally reasonable advice, but once specific medical treatment is forthcoming, the phone call should end quickly. There should be no expectation on either end of the line that leaves the impression that any medical problem has been concluded or solved by a phone call. The patient should not be expected to delay care or proceed on a course of home treatment based on a brief telephone call.
Probably the emergency physician is the best individual to give phone advice. Universally, this does not occur, with the caveat to the patient that “the doctor is too busy seeing other patients.”
I like that standard response of “call 9–1-1.” I also like, “Why don't you come to the emergency department so we take a look at you?” Even when given the option of being seen, the patient is often reluctant to come to the ED, usually put off by previous experience or potentially long waiting times. In certain circumstances, you can assure them that efforts would be made to address their problem in an expeditious manner, especially if their case sounds particularly concerning or pressing.
If for some reason a phone call makes its way to my phone line, I will tell the patient to come to the ED and ask for me. Better yet, I give him the name of my replacement or a resident. Don't forget to inform your triage nurse of your promise. This allows triage to inform you of the patient's arrival for a quick physician once-over or paves the way for priority intervention. When you can pull this off, it's the ultimate coup in public relations.
One exception to the “no phone advice” rule is the patient who has recently been seen in the ED, and is calling with a problem or for clarification of discharge advice or medication questions. Although nurses also usually field these calls, I would prefer that all patients who have been seen by a physician have some access to that physician or a colleague. This is especially true if they need clarification or complex information about a recent visit. Most written discharge instructions tell the patient to return or call the ED if they have any problems, concerns, or require clarification. Negating the good-faith option you just gave them in writing is neither prudent nor patient-friendly.
Although every ED has more patients than it probably ever wants, there is a role for public relations with such an encounter. Patients expect the same advice from their pediatricians or general practitioners, and nothing annoys a patient more than not having a doctor return a phone call or being unable to speak with “their ED doctor” after they just established a relationship. Usually these calls can be dispensed with a quick answer of a simple question, but the vast majority of complicated issues would require a repeat visit to the ED.
I wouldn't try to handle a colleague's discharged patient with chest pain, abdominal pain, vomiting, or fever over the phone. Those get an automatic: “Come back, and ask for Dr. Roberts.” Many times they won't follow this advice, but at least you gave them the option. If I do advise a return visit, I always make an attempt to document on the chart a note about this encounter, and clarify what advice was given, but that often falls through the cracks. It would be nice if the treating nurse would document a post-ED visit conversation, too. Certainly if I were a recently discharged patient and was told to call if I had any questions, I would be discouraged by most of the conversations I overhear when a busy nurse gets that suggested call.
Of course, the more problematic patients are those who call back looking for a lab test, the nefarious lost Percocet prescription, or the relative who wants a clarification of a complex six-hour ED visit that included a CT scan and multiple laboratory tests. The HIPAA laws have short-circuited much of this activity. If a patient calls me for results of a gonorrhea culture that was done two days before, I generally ask them some identifying information, such as social security number or date of birth, and hope that I am giving the information to the proper patient. If it's an HIV test result or abnormal findings on an MRI, I will have them come back for an on-site discussion. Again, this approach is time-consuming, takes away from efficient flow in the ED, and is fraught with all sorts of potential problems.
Finally, let's not forget the real medico-legal issues. It's not just paranoia; you can get sued for improper phone advice, and the chance that you documented even a pristine telephone encounter is negligible. The discouraging part of our legal system is that the expectation of patients receiving telephone medical advice is not significantly less than those actually seen in person. Although few cases of ED telephone advice ever reach the state of the malpractice claim, it's only a matter of time until this is added to the lawyer's armamentarium.
Emergency Department Telephone Advice Verdile V, et al Ann Emerg Med 1989;18:278
This is one of many studies that was designed to determine the consistency and accuracy of directions given to individuals who call the ED seeking medical advice about a potentially serious medical problem. In this study, 46 Pennsylvania EDs were selected and telephoned by a research assistant. Both teaching and nonteaching hospitals were included in this study as well as hospitals in urban and suburban locations. A few of the hospitals were Level I trauma centers, and nine had a residency program. Most of the EDs had a patient census of between 20,000 and 40,000 visits per year. (They were likely understaffed and overcrowded.)
The investigator presented a scripted scenario to ED personnel that reasonably could have been interpreted as a patient experiencing myocardial ischemia. The caller reported that her father was having indigestion and serious heartburn, and asked what she should do. If the ED responder asked additional information about the patient to clarify the condition, the caller was able to say that the patient had no previous heart history, but was a smoker. If asked, the heartburn could be described as severe and presenting as a squeezing sensation in the chest, with nausea and sweating that began at rest about 20 minutes earlier. A second investigator monitored the phone call and transcribed the conversation. The ED was not notified that it was being monitored or that the call was part of a research study.
The caller first asked to speak to a doctor, but presented the scenario to whoever answered the phone. The specific information gathered included who answered the call, what questions were asked to clarify the event, and what advice was given. Finally, it was noted whether the individual answering the phone considered whether this was a possible cardiac issue.
Only two of the 46 EDs permitted the caller to speak to a physician although the ED had a physician on duty at all times. Four of the 46 calls were given to the ED clerk or secretary, and the remaining (87%) were answered by an ED staff nurse. Interestingly, none of the respondents in the ED asked to speak to the patient directly, but relied on information relayed by a relative.
More than half of the ED respondents failed to ask any further questions to clarify the situation with regard to chief complaint or additional signs or symptoms. Even though approximately half of the ED responders suggested that myocardial ischemia was a possibility, only four of the 20 who voiced that this could be a cardiac condition suggested that the caller dial 9–1-1 or come to the nearest hospital immediately. About 60 percent of those giving advice suggested that the caller bring the patient to the ED, but only a few recommended that ambulance or paramedic transport be initiated. One ED that served as a paramedic base station offered to dispatch their paramedics to the caller's location.
Three of the EDs refused to give any information at all or any advice over the phone. They stated that it was the hospital policy not to give advice over the phone. About a third of the EDs suggested antacids, even though additional information suggested that the patient could be experiencing myocardial ischemia. Amazingly, one ED told the caller to give the patient nitroglycerine every five minutes, and that if the pain persisted, it was not likely cardiac. Where this imaginary patient was to obtain nitroglycerine was not forthcoming.
The authors concluded that telephone advice given by EDs is inconsistent and inadequate, and can jeopardize the welfare of those seeking advice. Information is often imprecise, and even when accurate, it may contain technical terms not likely understood by the general public. Although some hospitals designate a single staff person to answer calls for medical advice and have developed standardized protocols, advice, and documentation, this is not a common scenario.
The authors quote studies concerning pediatricians who have more experience and more exposure to telephone assessment and managing patients than emergency physicians. They state that studies have shown that as much as 12 percent of the pediatrician's day and approximately 27 percent of the pediatrician's total week is spent on the telephone answering medical questions. In a survey of pediatric residency training programs, fewer than half offered any training in telephone management of patients.
Isaacman, et al (Pediatrics 1992;89:35) demonstrated equally dismal results with phone advice dispensed from pediatric EDs. Apparently pediatric EDs are more like adult EDs, and do not simulate a pediatric office. When hospitals were presented with a mock phone scenario of a 5-week-old infant with symptoms classic for meningitis, the ED personnel (predominately nurses) demonstrated numerous shortcomings in eliciting further critical information and in giving accurate medical advice. In this febrile 5-month-old, only two-thirds even suggested same-day physician evaluation. Despite fever, irritability, and lethargy, some EDs did not even advise a prompt medical evaluation. Not a single hospital offered to ensure or facilitate transport to the ED.
The authors summarize their results by stating that it was not surprising that working emergency physicians were not available to give medical advice, this being a common scenario in an often hectic ED. There was concern that almost 10 percent of the calls were handled by an ED secretary or clerk with no formal medical training. It appears to be most common that ED nurses answer telephone calls for medical advice. Efforts on training and instructing nurses on how to perform this duty would likely be productive.
Comment: This is indeed a very discouraging report, but similar information has been reported elsewhere with other mock scenarios. I believe it proves that no ED can get it right. Essentially, it's an impossible expectation that proper, serious medical advice can be dispensed over the telephone under ED conditions. It has been my experience working with the poison center that the poison information system in this country is about as perfect as one can get.
Calls are screened by trained personnel, a detailed medical record concerning the encounter is kept, trained individuals provide basic advice, follow-up is ensured in selected cases, and physicians are available for back-up or further intervention. Studies have demonstrated that poison centers have reduced the number of needless ED visits, and are well worth the tax dollars allocated to support them. Such a system simply cannot be maintained in an ED in today's environment.
Most ED personnel are clued in to the obvious issues and probably try to dispense useful but minimal medical information over the phone. I am convinced, however, that in some cases there is a natural inclination for busy medical personnel to try subliminally to avoid yet another patient coming to the ED when they give phone advice. However, trying to decrease ED visits by giving medical advice over the phone is a worthless endeavor. Most managed care organizations and physicians' offices also have given up that fantasy. It's preferable to allow the patient better access to direct medical care than to steer them to a less urgent environment, your own system, or try to convince them to wait until tomorrow.
Attempting to maintain a detailed record of all telephone interventions is counterproductive and likely a false sense of security. Continuing education in the era of agency nurses and part-time personnel also is difficult. Probably a better way to handle this frustrating problem is to have scripted or standard protocols, keep advice at a minimum, and ultimately advise all patients to come to the ED for further evaluation. Some callers will likely be put off or insulted by the terse response, and probably the majority will never follow your sage advice.
Most patients and family members should understand that it is difficult to diagnose someone over the telephone. Giving them even the slightest hope that they will get special treatment or at least be guaranteed an evaluation in the ED would probably allay most of their fears. Probably the worse thing to do is to dismiss a fever, indigestion, or a poorly described pain or condition as benign or one that can wait for an office evaluation. It's unrealistic and not standard to expect that the ED will have a bevy of treatment protocols to be dispensed to the public or expect that the ED can maintain vigorous quality assurance mechanisms or keep accurate documentation of an impromptu phone call.
Finally, the medico-legal hazard of picking up the telephone in the ED is just another situation in which the emergency physician cannot win. The public clearly has false expectations. If the emergency physician hears a disastrous phone interaction between the nurse/clerk and a patient, he should grab the phone and try to avert a potential public relations or medical disaster. “I think you should come to the ED, and we would be happy to see you, regardless of your ability to pay” can never be bad advice. That concept should be written in everybody's policies and procedure manual.
Telephone Advice from the ED: Policy Statement by the American College of Emergency Physicians
“Emergency departments (EDs) often receive telephone calls from the public seeking medical advice. Each ED should have a procedure to identify the nature of all incoming calls. An individual whose call may concern a life- or limb-threatening medical emergency should be instructed to access the emergency medical services (EMS) system. Calls from patients recently discharged from the ED should be managed according to prearranged protocols that include the circumstances in which the patient should return to the ED.
“Most medical conditions cannot be accurately diagnosed by telephone; however, individuals often call the ED seeking general medical information or advice. With the exception of the above situations, the American College of Emergency Physicians (ACEP) recommends that EDs do not attempt medical assessment or management by telephone. Callers should be advised that EDs are available at all times to assess their condition.”
Source: Approved by the ACEP Board of Directors, July 2000; www.acep.org.
Scripting as a Method of Quality Assurance for ED Telephone Advice
When a patient calls the ED seeking medical advice, a nurse is designated to handle the call. The nurse can defer to a physician at any time, and is mandated when there is a perceived serious medical problem, a problem with a recent ED encounter, a complaint, or a public relations issue.
Initial Nurse Contact: Hi, my name is _________. I am an ER nurse. I would be happy to speak with you and see what I can do to help.
Listen to caller
If the call is a true emergency:
* ▪ Give basic first aid advice (pressure on bleeding, irrigate an eye, cool a burn, etc.).
* ▪ Advise activation of the EMS system or transport to the nearest hospital.
If the call is about a medical problem or requesting advice:
* ▪ “As you can imagine, it's nearly impossible to make a diagnosis or give accurate medical advice over the phone, especially without knowing the patient or actually seeing him. To get you the best care or advice, I think it best that you call your doctor if you have one and can contact him, but of course we would be happy to see you in the ED at any time, with any problem, and evaluate the situation, even if you do not have insurance or the ability to pay.”
If the call is about lab results:
* ▪ “I would like to help you, but there is a federal law that does not allow me or the hospital to give out that sort of information on the phone. It is considered confidential and sensitive information, and it must be delivered in person. Your doctor can get the results for you, or you can come to the ED and speak directly to us. Bring identification when you come.”
If the patient was specifically told to call back for results
If the call is about a recent visit, and there is a question about what to do, where to go, etc.:
* When a simple question is asked: “Maybe I will be able to help you. What is your question?”
* Using discretion, answer the question to the best of your ability.
* When a complicated question is asked: “Let me take some information (take name, address, phone number), and I will get the chart. I can have someone try to get back to you, or you can hold while I try to answer your question. Please be patient because the ED is very busy.”
(>If this is a continuing medical problem, side effect, concerning symptom, complaint, or complicated issue, the physician should handle the call personally.)
If the call is to ask about a condition, diagnosis, or status of a patient:
* ▪ ”I would like to help you, but there is a federal law that does not allow me or the hospital to give out that sort of information on the phone. It is considered confidential and sensitive information. I can take your number, and the patient can call you. You can always come to the hospital and get firsthand information from the patient or the medical staff. (If this is a parent of a child, physician, or someone able to supply important information, the call is handled by the physician on duty.)
© 2005 Lippincott Williams & Wilkins, Inc.