Do after hours nurse call centers send too many kids to the emergency room?

A large number of pediatric practices these days use after-hours call centers for parents who have questions about a sick child. I’ve been looking around to find some data about how common this is, but my sense is that the majority of pediatricians use them. There is no question these call centers make live easier for the doctor; having somebody screen the calls, answer easy questions, and only call you for important issues is a great boon. But that boon comes at a cost: the people staffing the call centers are not doctors. They are often experienced nurses, but that is not the same thing. So deciding what is important and what can wait can be a problem.

The call centers generally use predetermined protocols drawn up by experts to help guide decision-making. This is a good way to ensure consistent, quality advice. But not every child fits the protocol, and a set of guidelines is not a substitute for actual clinical experience. Really, these days a savvy parent can get almost as much useful guidance from consulting Dr. Google (or my latest book). A study presented at the most recent meeting of the American Academy of Pediatrics examines another question: do these call centers send too many children to the emergency department?

My assumption would be that they do. After all, they are hard-wired to do so. If you call one, the person giving you advice not only is not a doctor, they do not know your child. Also, the decision-making protocols they use necessarily err on the safe side. So if there is any doubt about what to do they will advise you to take your child to the emergency department even though your child’s doctor often might not do that.

The study bears out this presumption. The investigators, from Children’s National Medical Center in Washington, D.C., examined the records of 220 children for whom the call center advised parents to take their child to the emergency department. They used a panel of evaluators to see if the visit to the ED was appropriate. They found that, for a third of the children, they could have safely stayed home.

After-hours call centers have made doctors’ lives less hectic, and I’m not suggesting we do away with them. They give thousands of parents useful advice. Plus, what we don’t know is if even more of those 220 children would have ended up in the ED if the call center didn’t exist: who knows, perhaps they steered a significant fraction of children away from an inconvenient and expensive ED visit. However, in my own anecdotal experience the call centers do increase ED use. I have had many parents tell me, after I’ve seen their child in the ED, that the only reason they came was that the call center told them t0 — that they were surprised by that advice and otherwise would have stayed home.

My own father was a small town pediatrician. He didn’t have an answering service. When parents wanted to ask about their sick child they just called him at our home. His phone number was in the directory just like everybody else’s. He didn’t have any sort of pager. If he wasn’t home, people called back or else called whatever number one of us kids or my mother told them to call to find him. Those were simpler times, and not necessarily better ones. Now we have call centers, and we need to figure out how best to use them.

I’d be interested in any experiences, good or bad, that parents have had with after-hours call centers. Were they helpful? Were they a problem?


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