Abstract: Results of a Pilot Project to Introduce Call Triage Services in Churchill Falls, Labrador

Authors

Andrea White RN (Contact)

Regional Director (Community Clinics Services)

Health Labrador Corporation

Ph.: 709-897-2260

Fax: 709-896-0958

Email: awhite@hlc.nf.ca

Donna Matthews RN

Director of Client and Professional Services

FONEMED North America

139 Water Street

St. Johns, NL A1C 1B2

Ph.: 709-726-4567

Fax: 709-726-4512

Email: dmatthews@fonemed.com

Introduction

In August 2002, the Community Clinics division of Health Labrador Corporation and the Rural Health Academic Centre initiated a pilot project arrangement with FONEMED®, a call triage centre, as a solution to assisting health care professionals manage after hours care in the community of Churchill Falls, Labrador.  It was proposed that the project would allow the organization to evaluate a call triage system for expansion throughout the Health Labrador region, based on effectiveness and cost efficiency.

Call centres provide a choice for residents who may not necessarily need to see a healthcare professional after hours, but who require reassurance that they have made the correct decision about a plan of care. Nurses at the call centre ask callers questions about their symptoms in order to assist them in determining the most appropriate plan of care.  Nurses use approved medical protocols, to deliver the best advice for the client, whether it is accessing emergency services, seeing a health professional within a specific time frame, or using self-care.  Nurses working in Medical Call Centres complement the current health care system by providing timely, after hours advice to the patient thus preventing unnecessary visits to the ER or recommending an Emergency Room visit to a patient who otherwise would not have gone.

Churchill Falls is an industrial community located in the heart of Labrador.  With only a gravel highway extending to the remote communities of Happy Valley-Goose Bay on one end and Labrador City and Wabush on the other, it is virtually isolated from a health care point of view. Without the benefit of extended families in close proximity, and lacking the advantage of a wide array of health related community resources, Churchill Falls residents telephone the on-call primary care practitioner because it is often their only option to get the health information they need. 

Health Labrador Corporation operates a primary health care clinic in the community.  The nurse and physician (the PHCPs or Primary Health Care Practitioners) share after hours on-call duties, with the RN working in the expanded role of Regional Nurse assessing, diagnosing, treating and prescribing medications. While availability of a PHCP is required for after-hours trauma and emergencies (approximately 4 per month), the majority of the callbacks are for non-urgent care (approximately 14 per month).  These numbers do not include phone calls from clients seeking health information after hours (not necessitating a ‘call-back’), nor does Health Labrador Corporation collect data in this regard.

Specific Results

Retrospective Review of FONEMED Dispositions

A retrospective review of FONEMED's Telephone Encounter reports was performed. The period studied was from 2002 September 1^st to 2003 February 1^st.  During the study, all after hours and weekend calls to the clinic were call forwarded to FONEMED.  Following a telephone assessment, an encounter report was faxed to the clinic to be placed on the client’s health record.  For this aspect of the study, the final assessment on the call centre encounter report was removed and the report given to an experienced Regional Nurse to determine her recommendation based on the assessment answers. The two dispositions were then compared to determine the number of calls saved and a cost analysis developed.

In 73% (n=37) of the 50 reports analyzed, the Regional Nurse’s disposition was the same as FONEMED. 

In 22% of the cases (n=11), the call centre nurse recommended earlier intervention than the Regional Nurse advised. This was in contrast to the original expectation, and the encounter sheets were further analyzed.  The following was determined:

·      The Regional Nurse doing the retrospective review found insufficient information on the FONEMED encounter report to make a determination (n=6).  (Only positive responses to the protocols are shown on the report; negative responses to the assessment are not included on the sheet.)

·      The Regional Nurse doing the retrospective review indicated that she would have advised the client to use their prescribed medication on a prn basis (n=2). FONEMED does not dispense such advice regarding prescription medications.

·      The remaining dispositions (n=3) were determined according to medically accepted protocols for foreign body in the eye, open incision and chest pain. For presentation of a corneal foreign body the Canadian Trauma and Acuity Scale (CTAS), now being implemented as a national triage standard for Canada's emergency health care system, recommends time to practitioner assessment as 60 min.; for dressing changes 120 min., and for chest pain, 30 minutes.  While FONEMED's recommendations were within these guidelines, the Regional Nurse’s were not.  Thus, FONEMED's triaging, based on predetermined protocols, potentially reduced risk to the patient and the organization.

Other factors may also come into play when comparing the dispositions.  The first possibility is that of a ‘study bias’.  The fact that the Regional Nurse knew her responses were being studied may have had an effect on her overall results.   

The experience and confidence of the Regional Nurse is also a factor in assessing clients, as is the nurse’s knowledge of the community.  Neither of these was accounted for in the study.

In 4% (n=2) of the cases, the Regional Nurse indicated that she would have intervened sooner than that recommended by FONEMED. Further analysis indicated that the call centre had provided instruction to the client to call back should the condition deteriorate.  In one case, the condition did not worsen, but in the other, the client’s condition deteriorated and FONEMED upgraded the disposition.

Callback and Overtime Cost Analysis

The number of callbacks and the overtime hours for 11 corresponding pay periods in the year prior to and during FONEMED were tabulated and compared. Data was taken from the respective overtime and callback information submitted on the Regional Nurse timesheets. Given the fluctuations in population from season to season, comparison over two years was more favourable than a single year comparison.   To discount the possibility of spurious results, the pilot project data was also compared to data from two years previous, with similar outcome. 

The ‘01/’02 data reveal gross savings of $7,856.25.  When compared to ‘00/’01 data, gross savings of $3,425.00 were realized over the project period. Net savings for the FONEMED pilot period were $5876.00 (‘01/’02), and $1545.00 (‘00/’01). 

Regional Nurses are entitled to receive overtime pay for each work-related interruption after normal working hours.  In accordance with the NLNU Collective Agreement, the minimum charge is for 0.5 hrs.

During the six month period examined, 23% of the callers received self care advice (n=13), and 18% were advised to see their primary care provider in 24 to 72 hours (n=10).  For each disposition in which home care was recommended, information was provided, or a visit to the PHCP was delayed for more than 23 hours, an overtime payment of  $20.63 (mean hourly salary * 0.5 hrs. * 1.5 rate. ) was saved.   For the pilot period, this amounts to $475.00. 10% were directed to see a practitioner in 4 to 24 hours (n=6), and 41% of callers were sent to the clinic immediately. (n=23).

Conclusion

The evaluation revealed that the call centre service not only offers clients an accessible and viable option to get trusted and reliable advice on what to do, it also provides a practical and positive adjunct for the Health Labrador Board in delivering health care to remote and isolated communities.